"Mental Health and Substance Abuse Outpatient Discharge Form" - Delaware

Mental Health and Substance Abuse Outpatient Discharge Form is a legal document that was released by the Delaware Department of Services for Children, Youth and their Families - a government authority operating within Delaware.

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Download "Mental Health and Substance Abuse Outpatient Discharge Form" - Delaware

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MENTAL HEALTH AND SUBSTANCE ABUSE OUTPATIENT DISCHARGE
DEPARTMENT OF SERVICES FOR CHILDREN, YOUTH & THEIR FAMILIES
DIVISION OF PREVENTION & BEHAVIORAL HEALTH SERVICES
1825 Faulkland Road Wilmington, DE 19805 (302) 633-2571 or (302) 633-2591
Please fill out this form completely and call if you need assistance.
Fax this form to (302) 622-4475
Client Name: ____________________________________
DOB: ____________________
Discharge Date: ______________
Agency: _______________________________
Therapist: ___________________________________
Phone: _________________________
Reached Age of 18
Y
N
Reason for discharge: ___________________________________________________________
Outcome of Treatment: ____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Client’s discharge diagnosis (DSM IV including codes):
MENTAL HEALTH AND SUBSTANCE ABUSE OUTPATIENT DISCHARGE
DEPARTMENT OF SERVICES FOR CHILDREN, YOUTH & THEIR FAMILIES
DIVISION OF PREVENTION & BEHAVIORAL HEALTH SERVICES
1825 Faulkland Road Wilmington, DE 19805 (302) 633-2571 or (302) 633-2591
Please fill out this form completely and call if you need assistance.
Fax this form to (302) 622-4475
Client Name: ____________________________________
DOB: ____________________
Discharge Date: ______________
Agency: _______________________________
Therapist: ___________________________________
Phone: _________________________
Reached Age of 18
Y
N
Reason for discharge: ___________________________________________________________
Outcome of Treatment: ____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Client’s discharge diagnosis (DSM IV including codes):