*Form must also be completed when client is transferring out of a program.
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Client Code: Client Name: _______________________________________________
Termination Date: Location: __________ Program No: _________ Staff No: _________
Reason for Term: (Circle one)
A. Termination w/referral F. Lost/Follow-up unsuccess.
B. No further services needed G. Lost/No follow-up
C. Further Services not available H. Client moved
D. Services rejected by client J. Client Died / on premise
E. Services rejected by parent K. Client Died / off premise
Status:
G. Terminated: IC (Primary caretaker)
H. Terminated: Non-IC (at-risk children)
J. Terminated: ID Enrollee (Secondary caretaker)
K. Terminated: Non-ID Enrollee (all others)
L. Terminated: No Services Received
Living Circumstances: (Circle one) A. Alone/Indep. B. With Relatives/Family
Residential Arrangement: (Circle one)
A. Private Residence
B. Cooperative Living Situation
C. Foster Family Care
C. Other
L. Children's Group Home/Teaching Family Program
M. Homeless Shelter
N. Other Residential Program
D. Homeless/On Street
E. Community Residential Program
(With MH Svcs)
F. Boarding Home/RHCF
G. Nursing Home/SNF/ICF
H. Residential Substance Abuse Prog.
J. DDD/MR Residence
K. DYFS Residential Treatment Center
Primary Agency Follow-up: (Circle one)
O. State Psychiatric Hospital
P. County Psychiatric Hospital
R. CCIS Inpatient
S. Other Psychiatric Inpatient
T. State Correctional Facility
V. Detention Center
W. Other Institutional Setting
X. Unknown
1. Private Psychiatrist
2. Medical Doctor
3. Clergy
4. DYFS
5. DDD
6. Other
7. No referral
H. Community Mental Health Agency
J. Alcohol Treatment Program
K. Drug Treatment Program
L. School System
M. Other Social Service Agency
N. Nursing Home
O. Boarding Home
A. Designated Screening Center
B. Short Term Care Facility
C. CCIS Inpatient
D. County Psychiatric Hospital
E. State Psychiatric Hospital
F. Other Psychiatric Inpatient
G. General Hospital
P. Homeless Shelter
R. Other Residential Program
S. Police/Court/Jail
T. State Correctional Program
V. Community Corrections Program/Parole/Probation
W. Family Crisis Intervention Unit
X. Private Mental Health Practitioner
Level of Functioning at Closing (1-10 or U-Unknown) __________ GLOF: _________

*Form must also be completed when client is transferring out of a program.
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Service Program Needs:
A. Crisis Stabilization/Emergency Services
B. CCIS Inpatient
C. Other Psychiatric Inpatient
D. Client Advocacy
E. Daily Living Skills
F. Medication monitoring/Education
G. Partial Care
H. Psychological/Psychiatric Evaluation Only
J. Psychotherapy/Counseling
K. Self-Help Services
L. Service Coordination/Linkage
M. Community Residential Program
(with MH services)
Non M.H. Needs:
A. Alcohol Abuse Services
B. Correctional
C. Drug Abuse Services
One (1) month: _____/_____/_____
Three (3) month: _____/_____/_____
Six (6) month: _____/_____/_____
Twelve (12) month: _____/_____/_____
D. Education
E. Employment
F. Financial
G. Housing
FPS Outcome Codes (at-risk children only)
A - Still at home with original family
B - With relative
C - In other family-like setting
D - Runaway
E - Unable to contact family/unknown
F - Independent living
G - In detention
H - In shelter
I - In foster care
J - In group home
K - In in-state residential care
K - In out-of-state residential care
L - OTHER OUTCOME
O - In other out-of-home placement
R - In substance abuse rehab program
FPS Follow-Up Due Dates (for task/needs file):
N. Crisis Housing
O. Outreach/In-home Services
P. Residential Support Services
R. Respite Care
S. Pre-Vocational Services
T. Transitional/Supported Employment
V. Child Study Team Evaluation
W. DDD
X. DYFS
1. Information and Referral
2. Other
3. None
H. Legal/Justice
J. Medical/Health Related
K. Pastoral
L. Recreation
M. Transportation
N. Other
P. None
FPS Turnback Codes (IC Parent Only)
P1 - Child in danger
P2 - Child not at risk
P3 - Child placed before intervention
P4 - Family refused services/unavailable
PO - Other (specify)