Mental Health Discharge Planning Checklist Form
Please complete this checklist to ensure all discharge planning steps are addressed prior to leaving care.
Patient First Name
Patient Last Name Initial
Discharge Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Tasks Checklist
Discharge instructions provided and reviewed
Medication list reviewed (if applicable)
Follow-up appointment scheduled or discussed
Support contact information provided
Community resources and referrals offered
Safety plan discussed
Transportation or next steps confirmed
Questions answered
Additional Notes or Comments
Staff Name (Person completing this form)
First Name
Last Name
Date Completed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Checklist
Should be Empty: