HPN Long Term Bed Discharge Form
Some question on this form are assigned a point value. This will allow us to determine the clients level of success and your input is invaluable. For a client to achieve a successful outcome, s/he MUST score a minimum of 65 points. Please answer each question thoughtfully as this will allow us to determine areas in the program that are strong and those we need to review.
Discharge Score
A score of 65+ equals a successful discharge. FOR ADMIN USE ONLY
Discharge Date
*
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Facility
*
541 W. 2nd
529 W. 2nd
437 12th St
1195 Kings Row
Moran
Wright Way
1808 Pinewood
1169 LaVia
1150 Ryland
6540 Tejon Court
457 Cameo St
468 Clairmont St
Patton Dr
Was client employed on intake?
*
Yes
No
Not medically cleared to work
Was client employed on discharge?
*
Yes=10 points
No= 0 points
Not medically cleared to work= 10 points
Did client reunify with his/her family while at Life Changes?
*
Yes= 10 points
No= 0 points
Not applicable= 10 points
Did client pay his/her service fees as required?
*
Yes= 10 points
No= 0 points
Not applicable= 10 points
Did client use drugs/alcohol while in the program?
*
Yes= 0 points
No= 10 points
Was client clean/sober upon discharge from the program?
*
Yes= 10 points
No= 0 points
Unknown = 0 points
How many written notices of non compliance did client receive while in the program?
*
Zero= 10 points
2 or less= 5 points
3 or more= 0 points
Length of Stay
*
Less than 30 days= - 0 points
30 to 60 days= 5 points
60 to 90 days= 10 points
90 plus days = 10 points
Do you recommend the client for successful discharge?
*
Yes= 10 points
NO= 0 points
Why did you recommend the discharge status indicated in the question above?
*
Circumstance of Discharge
*
Completed program
Non compliance with program requirements
Client left of own accord prior to completion
Other
Additional Comments
Staff Completing Form
*
First Name
Last Name
Submit
Should be Empty: