Discharge Form

Discharge Form
Mentor Name *
First NameLast Name
Today's Date*
MonthDayYear
Date
Clients Name *
First NameLast Name
Clients Date of Birth*
MonthDayYear
Date

How long did the client engage in services*
Less than 1 month1 month to 6 months6 months to 1 yearMore than a year
How much sober time did the client achieve while in services?*
less than 30 days30 days to 90 days90 days to 6 months6 months to 1 year1 - 2 years
Did the client improve in any of the following areas (check all that apply):*
HousingEducationEmploymentReunited with kidsCompleted TreatmentDidn't get arrestedGot health insuranceStarted seeing primary care doctorAchieved some of their recovery goalsDrivers LicenseBought a car
Reason for discharge*
No longer needs recovery mentor supportNo longer wants servicesWent to jailUnknown: no contact for several monthsRelapsed and hasn't returned for support in over 3 months.Other
Is the client present?*
YesNo
Should be Empty: