Discharge Checklist

Document Name

Participant Initials

Staff Initials

Clinical

Restoration

Fatherhood Engagement

Family Connections

Case Name

Case Number

Service

Client Name (If Different)

Client Phone

Primary Staff

Family Present to Complete form?

Yes

Family Follow-up contact permission?

Yes

Final Discharge

Service Discharge

Referral Date

Referral Agency Contact at Discharge

RAC Phone

Referral Type:

Maintenance

Reunification

List three community resources and/or aftercare providers provided to the family/client at discharge.

All items have been completed and reviewed by a supervisor

Client Name

Signature Clear Signature

Date Signed

Staff Name

Staff Signature Clear Signature

Date Signed

Supervisor Name

Supervisor Signature Clear Signature

Date Signed