Rehab Program Cessation Log Form
Use this form to record the end of rehab participation, the reason for stopping, and any follow-up or referral needed.
Participant & Program Details
Participant Full Name
*
First Name
Last Name
Participant / Client ID
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rehab Program Name
*
Program Type / Category
*
Inpatient
Outpatient
Counseling
Support Group
Detoxification
Intensive Outpatient
Other
Primary Staff Member / Case Manager Name
Cessation Log Information
Cessation Log Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Rehab Services Stopped or Last Attended
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Participation Status at Cessation
*
Please Select
Completed
Discontinued
Transferred
Paused
Lost Contact
Other
Reason for Cessation
*
Please Select
Treatment goals achieved
Medical reasons
Scheduling or transportation barriers
Relocation
Program transfer
Administrative discharge
Client request
Lost contact
Other
Was the Cessation Planned or Unplanned?
*
Planned
Unplanned
Service Transition & Follow-up
Referred to Another Program or Service?
*
Yes
No
Receiving Service Name
Follow-up Contact Method
Preferred Follow-up Method
Phone
Email
Text
In-person
None
Follow-up Action Required
Please Select
None
Outreach Call
Re-enrollment Discussion
Referral Confirmation
Welfare Check
Other
Follow-up Date or Deadline
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Notes / Comments
Submit
Should be Empty: