Discharge Review

Client Name: Date of Birth: Success: 1-Low 2 3 4-High

Status: CHILD: not DCF/DJJ involved foster care protective svcs delinquent ADULT: competent incomp.

Current living situation:

DISCHARGE REVIEW ACTIVITIES

Review period: Intake: to discharge decision: Written by:
Notation of discussions:
Notified case mgr of DC? Attachments: N/A-Admin. DC Satisfaction Survey DC Rating CFARS/FARS

MOST RECENT DIAGNOSES

SUMMARY OF SERVICES PROVIDED
Clinician(s): 1st Session: Last: Months:
Interventions with client individually:
Interventions with support system (family/school/other):
FINDINGS/PROGRESS (changes in frequency, duration, or severity compared to intake)
Problem #1:
Problem #2:
Problem #3:
Problem #4:
Intake GAF: DC GAF: Findings (reasons for progress or lack thereof):
CONCLUSIONS & RECOMMENDATIONS
Conclusion: Decision to terminate services due to the following reason:
Goals met, no need for further treatment Parent/client requested termination
Goals NOT met, maximum benefit reached Other:
Inactive due to:
Recommended aftercare services are listed in the attached Aftercare Plan.

This review is effective as of ______. The following have provided input in the development of this plan:

______

Client Signature Date Primary Clinician Signature/Credentials Date

______

Parent Guardian DCM Signature Date Other Participant/Relationship Date

01/15

Discharge Aftercare Plan - ORM

Client Name: Date of Birth:

Instructions: Complete form and give a copy to the client/parent during the final session. Turn in original form with the Discharge Review. If services ended without a final session, the Adapt office will send a copy of this plan to the client/parent when it is turned in.

Reason for discharge
Decision to terminate services with Adapt due to the following reason:
Goals met, no need for further treatment Parent/client requested termination
Goals not met, maximum benefit reached Other: Other:
Inactive due to:
Current medications to continue
Current services to continue
Client is currently receiving the following services from other providers: No current services
1-Individual/Family Therapy 5-Residential treatment 9-Case management
2-Behavior Analysis 6-Substance Abuse therapy 10-Tutoring
3-Medication Management 7-Speech therapy 11-Mentoring
4-Support group 8-Occupational therapy 12-Other:
Service# from
Service# from
REFERRALS FOR New services RECOMMENDed (include contact phone # for provider if not on list below)
The following new services are recommended from other providers: No services recommended
1-Individual/Family Therapy 5-Residential treatment 9-Case management
2-Behavior Analysis 6-Substance Abuse therapy 10-Tutoring
3-Medication Management 7-Speech therapy 11-Mentoring
4-Support group 8-Occupational therapy 12-Other:
Service# from
Service# from

If services other than those listed above are needed, you may contact your insurance to request a list of network providers in your area. If you do not have insurance, the following agencies provide services for free or have reduced fees, based on the client’s ability to pay (sliding scale fees):

·  Halifax Behavioral: 841 Jimmy Ann Dr, Daytona Beach, FL 32114, 386-425-3900

·  Stewart Marchman/ACT: 1220 Willis Avenue, Daytona Beach FL 32114, 386-236-3200 or Access Center 800-539-4228

If the agencies listed above do not work out, you may call 211 (United Way Helpline) for other options.

Resuming services with Adapt: If services from Adapt are needed and wanted in the future, they can be restarted by completing a Referral Form found on the website (www.Adapt-FL.com) and faxing it to the local Adapt office. You may also calll the local office to make the referral:

Volusia/Flagler/St. John’s counties: 533 N. Nova Rd. #204, Ormond Beach FL 32174, 386-898-5003

Copy of Aftercare Plan given to client/parent during final session.

Copy of Aftercare Plan to be sent to client/parent after discharge. (date sent:______)

Clinician Signature: ______Date:______

03/13

Consumer Satisfaction Survey

Client: Staff: Date:

Your relationship to client: ¨Self ¨Parent ¨School personnel ¨Other:______

Does Not Apply / Strongly Disagree / Disagree / Agree / Strongly Agree
Services were started as quickly as possible. / 0 / 1 / 2 / 3 / 4
Services were provided on a consistent, regular basis. / 0 / 1 / 2 / 3 / 4
This staff responded to my calls quickly. / 0 / 1 / 2 / 3 / 4
This staff was supportive and caring to me/my child. / 0 / 1 / 2 / 3 / 4
I/my child felt comfortable with this staff. / 0 / 1 / 2 / 3 / 4
I felt free to disagree with this staff. / 0 / 1 / 2 / 3 / 4
This staff helped me find other services that I/my child needed. / 0 / 1 / 2 / 3 / 4
The services I/my child received were helpful. / 0 / 1 / 2 / 3 / 4
I/My child got better as a result of services. / 0 / 1 / 2 / 3 / 4
My/my child’s quality of life improved as a result of services. / 0 / 1 / 2 / 3 / 4
I am satisfied with the services I received. / 0 / 1 / 2 / 3 / 4
I would recommend this staff to other people who need this type of help. / 0 / 1 / 2 / 3 / 4
I would recommend this agency to other people who need this type of help. / 0 / 1 / 2 / 3 / 4

Additional comments you would like to share with us regarding your staff or the services you receive: ______

Signature:______

Revised 02/12

Discharge Rating - Consumer

Client Name: Date:

Staff Name:

Person Completing Rating: ______

Relationship to Client: ______

We are interested in finding out how much improvement was made as a result of our services. Please check one of the following categories that best describes your situation at the time that services with the above-named staff were stopped.

____ 1. NO SUCCESS: At the time that services were discontinued, the problems still happened as much as they did before we started working with you and the staff’s suggestions did not work or you decided not to do those things.

____ 2. LOW SUCCESS: At the time that services were discontinued, the problems had improved a little and you learned a little about what to do to make things better, but there were still a lot of problems.

____ 3. MODERATE SUCCESS: At the time that services were discontinued, the problems had improved a lot and you had learned what you could do to make things better, but the problems were still happening more than you would like and you were not always sure what to do about it.

____ 4. HIGH SUCCESS: At the time that services were discontinued, the problems were down to a manageable level and you felt confident about what you can do to keep things going well.

Comments:

Signature:______

Revised 11/12

CFARS (age 0-17)

Client Name: Client ID#: Intake Date: Age:

Instructions: Complete for all clients age 0-17 at admission, every 6 months & planned discharge

Revised 08/15

CFARS (age 0-17)

Current Evaluation Date:

Funder on date of evaluation:

Medicaid plans: Healthy Kids plans: Other plans:

13=AHCA 08=United 23=Amerigroup HK 49=CMS (non-Medicaid)

09=Amerigroup 99=ValueOptions/First Coast 114=Cenpatico HK 21=FSPT CBC-CF

70=Cenpatico 100=Wellcare 25=United HK 102=FSPT-CPC

111=Magellan 113=CMS-Title 19 (Medicaid) 104=Wellcare HK 00=Private insurance

12=PsychCare Other: Other:

Purpose of Evaluation:

1=Admission 2=Every 6 months 3=Planned discharge (within 3 weeks after last session)

Revised 10/12

CFARS (age 0-17)

No prob / Minor problem / Needs outpatient treatment / Hospitalization may be needed / Children’s Functional Assessment Rating Scale (CFARS)
(for clients age 0-17)
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / Clinical Domains
Depression: Depressed Mood, Sleep Problems, Sad, Hopeless, Withdrawn, Irritable, Lacks Energy/Interest, Anti-Depression Meds
Anxiety: Anxious/Tense, Guilt, Phobic, Worried/Fearful, Anti-Anxiety Meds, Obsessive/Compulsive, Panic
Hyperactivity: Manic, Inattentive, Agitated, Sleep Deficit, Overactive, Impulsivity, Mood Swings, Pressured Speech, Anti-Manic Meds, ADHD Meds
Thought Process: Illogical, Delusional, Hallucinations, Paranoid, Ruminative, Derailed Thinking, Loose Association, Anti-Psychotic Meds, Disoriented
Cognitive Performance: Poor Memory, Low Self-Awareness, Slow Processing, Attention/Concentration, Developmental Disability, Concrete Thinking,
Impaired Judgment
Medical/Physical: Acute Illness, Hypochondria, CNS Disorder Behavior, Chronic Illness, Need of Med/Dental Care, Pregnant, Poor Nutrition, Enuretic/Encoperetic, Eating Disorder, Seizures, Stress Related Illness
Traumatic Stress: Acute, Dreams/Nightmares, Chronic, Detached, Avoidance, Repression/Amnesia, Upsetting memories, Hypervigilance
Substance Use: Alcohol, Drugs, Dependence, Abuse, Over the Counter Drugs, Craving/Urge, DUI, Medical Control, Interferes with Functioning, IV Drugs
Interpersonal Relationships: Poor Social Skills, Overly Shy, Problems with Friends, Difficulty Establishing./Maintaining Relationships
Behavior in Home: Defies Authority, Disregards Rules, Conflict with Relative, Conflict with Parent/Caregiver, Conflict with Sibling/Peer
ADL Functioning: Handicapped, Permanent Disability,
Not Age Appropriate in: Communication, Self-Care, Hygiene, Mobility
Socio-Legal: Disregards Rules/Norms, Offense to Property, Offense to Persons, Firesetting, Probation/Parole, Pending Charges, Dishonest/Lying, Gang member, Uses/Cons Others, Incompetent to Proceed, Detention/Commitment
Work/School: Absenteeism, Skips Classes, Tardiness, Suspended, Dropped Out, Terminated/Expelled, Poor Performance, Learning Disability, Illiterate, Defies Authority, Disruptive Behaviors,
Danger to Self: Suicidal Ideation, Current Plan, Recent Attempt, Past Attempt, Self-Injury, Risk Taking Behaviors, Serious Self-Neglect, Inability to Care for Self
Danger to Others: Violent/Physically Aggressive, Threats, Causes Serious Injuries, Homicidal Ideation/Threats/Attempts, Uses Weapons, Cruelty to Animals, Sexual Assault
Security/Management Needs: Suicide Watch, No Harm Contract, Locked Unit, Protection from Others, Seclusion, Home with Supervision, Run/Escape Risk, Restraint, Involuntary Exam, Time-out, Monitored House Arrest,
One-to-One Supervision

Clinician Signature: ______Date:______

Revised 10/12