Emergency Shelter Discharge Form
Document the details of a resident's discharge from the emergency shelter, including resident information, discharge details, belongings, and follow-up needs.
Resident Full Name
*
First Name
Last Name
Resident Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Resident Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Resident Email Address (if available)
example@example.com
Discharge Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Staff Member Completing Discharge
*
First Name
Last Name
Reason for Discharge
*
Completed Stay
Voluntary Departure
Rule Violation
Transferred to Another Facility
Other
Discharge Destination
*
Permanent Housing
Transitional Housing
Another Shelter
Family/Friends
Unknown
Other
Checklist: Personal Belongings Returned to Resident
Clothing
Medications
Personal Documents
Mobile Phone
Other Items
Are there any follow-up needs or referrals required?
*
Yes
No
If yes, please specify follow-up needs or referrals
Additional Comments or Notes
Resident/Guardian Signature
*
Submit Discharge
Submit Discharge
Should be Empty: