Wellness Center Client Discharge Form
Complete this form to document the discharge process and provide aftercare information for clients leaving the wellness center.
Client Full Name
*
First Name
Last Name
Client Contact Information
*
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Provider/Practitioner Completing the Form
*
First Name
Last Name
Reason for Discharge
*
Treatment goals achieved
Client request
Non-compliance with program
Transfer to another facility
Other
Summary of Client's Progress and Achievements
*
Recommendations and Aftercare Instructions
*
Follow-up Arrangements (if any)
Would you like to provide feedback about your experience at the wellness center?
*
Yes
No
Please provide your feedback (optional)
Client or Guardian Signature
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: