Enclosure 24
FY 2013-14
PATH Program Discharge Summary
Client Name: ______________________________________________________________
Discharged to: _____________________________________________________________
Address: _________________________________________________________________
Phone: ___________________________________________________________________
Enrollment Date: _________________
Type of Discharge:
Low Impact
Medium Impact
High Impact
Discharge Date: _______________
(Dropped Out, Refused Service, Lost Contact)
(Remains Homeless but Linked to Mental Health Services)
(Temporarily or Permanently Housed and Linked to Mental Health Services)
HOUSING STATUS UPON DISCHARGE
1. Homeless:
Outdoors Abandoned Building Short-Term Shelter
Unknown
2. Temporary Housing:
Long-Term Shelter Homeless Service Center
Transitional Housing (up to 24 months)
Motel
Residential Treatment Program
Living with Family/Friends
3. Permanent Housing:
Supportive Housing Program
Shelter + Care
Section 8 Voucher
Leases Own Apartment/Room/House
Other ______________________________________________
4. Corrections or Institution:
Jail or Correctional Facility
Hospital
Nursing Home
Was Client’s Housing Status Improved from Initial Contact to Discharge?
YES
NO
Outcome Measures
OBTAINED FOLLOWING SERVICES AND RESOURCES DURING ENROLLMENT: Check
Housing (temporary, transitional, permanent)
Assisted
Attained
Mental Health Services
Assisted
Attained
Income Benefits (SSI/SSDI)
Assisted
Attained
Employment
Assisted
Attained
N/A
Medical Insurance or Coverage Plan
Assisted
Attained
N/A
Additional Services
General Assistance Income
California ID
Self Help (i.e. 12 step programs)
Dental Services
VA Benefits
Primary Health Care
CalFresh Program/ Food Stamps
TANF
Substance Abuse Services
Other _____________________________________________
DISCHARGE SUMMARY Comments:
_________________________________________________________________________________________
PATH Staff Name (Print): _____________________________________________ Date: _________________
PATH Staff Name (Signature):______________________________________
PATH 2013-14 Request for Application
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Enclosure 24
FY 2013-14
PATH Program Discharge Summary Instructions
A discharge summary is required for all PATH enrolled individuals. This information collected on the
discharge summary assists in collecting information for the Quarterly Performance Report and PATH
Annual Report. All of the above information is required to be collected upon discharge from the PATH
Program with the exception of address and phone number.
PATH 2013-14 Request for Application
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