TRANSITION OR DISCHARGE SUMMARY

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DISCHARGE SUMMARY TRANSITION SUMMARY
CONSUMER NAME:
Admission Date: Last Service Date: Discharge Date:
PRESENTING PROBLEM:
LIVING ARRANGEMENT AT LAST CONTACT:
Medications upon discharge

SERVICES PROVIDED
Diagnostic Evaluation
Psychiatric Assessment
Nursing Assessment
Medication Management
DIAGNOSTIC STATUS UPON DISCHARGE
Early Intervention Counseling/Training- Individual Parent Training
Brief Stabilization Counseling/Training-Group Parent Aide
Intensive Family Intervention Counseling/Training-Family Other (List):
Community Support Individual Behavioral Aide Other (List):

AXIS I
PROGRESS MADE TOWARD DISCHARGE/TRANSITION
Reason Discharged

Goals Met Goals Partially Met Goals Not Met

Goals achieved during
program participation

Outcome Score at Admission: 2nd Evaluation Outcome Score at Discharge:

CAFAS: CAFAS: CAFAS:
CONDITION ON DISCHARGE/TRANSFER
Much Improved Some Improvement Unchanged Worse
COMMENTS

Strengths
Needs
Abilities
Preferences
RECOMMENDATIONS FOR SERVICES OR SUPPORT/TRANSITION TO

Contact Location Telephone# Days/ Hours open

Select One....
JCCS Staff responsible for follow-up
SIGNATURES

Consumer Signature Date Consumer Printed Name

Guardian Date Guardian Relationship

JCCS Staff Signature, Credentials Date JCCS Staff Printed Name, Credentials
Was the consumer offered a copy of this Plan? Yes No — If no, why not?
POST DISCHARGE FOLLOW UP
How is client doing? Much Improved Somewhat Improved Unchanged Worse F/U contact unsuccessful
Comments
Client’s report of effectiveness
of post transition services
Additional services needed? Yes No If yes, plan to meet the need:

JCCS Staff Signature Date JCCS Staff Printed Name

BH16.01(b)-Transition or Discharge Summary Jireh Counseling and Consulting Service, Inc. RevOCT2008