Substance Abuse Discharge Form
Please complete this form to document the discharge process and ensure a safe transition from substance abuse treatment.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Substance Abuse Program
*
Please Select
Inpatient
Outpatient
Detoxification
Residential
Partial Hospitalization
Intensive Outpatient
Other
Primary Substance(s) Treated
*
Alcohol
Opioids
Stimulants (e.g., cocaine, methamphetamine)
Cannabis
Sedatives/Hypnotics
Other
Summary of Treatment Provided
*
Medications Prescribed at Discharge (if any)
Aftercare Instructions and Recommendations
*
Follow-up Appointment Date (if scheduled)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Name and Phone Number
*
Patient Signature
*
Submit Discharge Form
Submit Discharge Form
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