DJJ Form MHSA011 "Mental Health/Substance Abuse Treatment Discharge Summary" - Florida

What Is DJJ Form MHSA011?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2014;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DJJ Form MHSA011 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form MHSA011 "Mental Health/Substance Abuse Treatment Discharge Summary" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
MENTAL HEALTH/SUBSTANCE ABUSE
TREATMENT DISCHARGE SUMMARY
Youth’s Name
DOB
Sex
Race
JJIS No.
Facility Name
Circuit
1.
D a t e M e n t a l H e a l t h
D a t e M e n t a l H e a l t h
T r e a t m e n t E n d e d :
T r e a t m e n t S t a r t e d :
D a t e S u b s t a n c e A b u s e
D a t e S u b s t a n c e A b u s e
T r e a t m e n t S t a r t e d :
T r e a t m e n t E n d e d :
2. Relevant Mental Health and/or Substance Abuse History:
3. Reason Mental Health and/or Substance Abuse Treatment Terminated:
4. Problems Which Were Focus of Mental Health and/or Substance Abuse
Treatment:
5. Summary of Mental Health Treatment and/or Substance Abuse Treatment and
Youth’s Progress in Treatment:
R u l e 6 3 N - 1 , F . A . C .
M H S A 0 1 1
O c t o b e r 2 0 1 4
P a g e 1 o f 2
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
MENTAL HEALTH/SUBSTANCE ABUSE
TREATMENT DISCHARGE SUMMARY
Youth’s Name
DOB
Sex
Race
JJIS No.
Facility Name
Circuit
1.
D a t e M e n t a l H e a l t h
D a t e M e n t a l H e a l t h
T r e a t m e n t E n d e d :
T r e a t m e n t S t a r t e d :
D a t e S u b s t a n c e A b u s e
D a t e S u b s t a n c e A b u s e
T r e a t m e n t S t a r t e d :
T r e a t m e n t E n d e d :
2. Relevant Mental Health and/or Substance Abuse History:
3. Reason Mental Health and/or Substance Abuse Treatment Terminated:
4. Problems Which Were Focus of Mental Health and/or Substance Abuse
Treatment:
5. Summary of Mental Health Treatment and/or Substance Abuse Treatment and
Youth’s Progress in Treatment:
R u l e 6 3 N - 1 , F . A . C .
M H S A 0 1 1
O c t o b e r 2 0 1 4
P a g e 1 o f 2
MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT DISCHARGE SUMMARY
6. Beginning Diagnoses
DSM-IV-TR Diagnoses
DSM-5 Diagnoses
Axis I
Axis II
Axis III
Axis IV
Axis V
7. Ending Diagnoses
DSM-IV-TR Diagnoses
DSM-5 Diagnoses
Axis I
Axis II
Axis III
Axis IV
Axis V
8. Youth’s Alert Status and Mental Status at discharge:
S u i c i d e R i s k
M e n t a l H e a l t h
S u b s t a n c e A b u s e
M e d i c a l
9. Psychotropic Medications youth has been receiving and to be continued upon
d i s c h a rge from the facility/program:
10. Continuing Mental Health Treatment and/or Substance Abuse Treatment or
Services Recommended Upon Transition/Dischar ge:
11. Referred to the following mental health and/or substance abuse providers:
( L i s t f o l l o w - u p a p p o i n t m e n t s , c o n t a c t n a m e s a n d t e l e p h o n e n u m b e r s )
M e n t a l H e a l t h / S u b s t a n c e A b u s e
Y o u t h ’ s S i g n a t u r e / D a t e
C l i n i c a l S t a f f P e r s o n ’ s S i g n a t u r e / D a t e
L i c e n s e d M e n t a l H e a l t h P r o f e s s i o n a l ’ s
P a r e n t / G u a r d i a n S i g n a t u r e / D a t e
S i g n a t u r e / D a t e
T r e a t m e n t T e a m M e m b e r / D a t e
T r e a t m e n t T e a m M e m b e r / D a t e
T r e a t m e n t T e a m M e m b e r / D a t e
T r e a t m e n t T e a m M e m b e r / D a t e
R u l e 6 3 N - 1 , F . A. C .
M H S A 0 1 1
O c t o b e r 2 0 1 4
P a g e 2 o f 2
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