MULTI-COUNTY COUNSELING, INC.
DISCHARGE SUMMARY
Therapist:_______________________________
Name and Credentials
Client Name: ________________________________ DOB: ______/ ______/ ______
Outpatient Admission Date: ______/ ______/ ______
SSN: ______/ ______/ ______
Outpatient Discharge Date: ______/ ______/ ______
Presenting Problem at Admission/Intake: ________________________________________________________________
____________________________________________________________________________________________________________
Treatment Issues Identified by Client at Admission: ________________________________________________________
____________________________________________________________________________________________________________
ADMITTING DIAGNOSIS
Axis I : ____________________
DISCHARGE DIAGNOSIS
Axis I : ____________________
Axis I : ____________________
Axis I : ____________________
Axis I : ____________________
Axis I : ____________________
Axis II : ____________________
Axis II : ____________________
Axis III : ____________________
Axis III : ____________________
Axis IV : ____________________
Axis IV : ____________________
Axis V : _________ / _________
Axis V : _________ / _________
Current
Highest Past Year
Current
Highest Past Year
ASAM Placement at Admission: ___________________________ (As applicable to treatment provided client)
Stage of Change at Admission: _____________________________ (As applicable to treatment provided client)
STRENGTH, NEEDS, ABILITIES AND PREFERENCES OF CLIENT AT DISCHARGE: ___________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
TREATMENT PROVIDED
 Outpatient Mental Health Treatment
 Outpatient Substance Abuse Treatment
 Integrated Outpatient Treatment [Mental Health / Substance Abuse]
 Other: ____________________________
SERVICES PROVIDED (Check all that apply)
 Individual Therapy
 Interactive Therapy
 Group Therapy
 Family Therapy
 Individual Drug/Alcohol Counseling
 Group Drug/Alcohol Counseling
 Family Drug/Alcohol Counseling
 Individual Rehabilitation
 Group Rehabilitation
 Drug/Alcohol Education
 Parenting Education
 Medication Management (by referral) [Providing Physician Name: _________________________________ ]
 Support Group (by referral) [Specify type and/or name of support group: _________________________________ ]
 Sheltered Workshop (by referral)
 First Offender (by referral)
 Psychological Testing (by referral)
 Case Management -Adult (by referral)
 Case Management -Child (by referral)
 Other: __________________________________________________________________________________________
REASON FOR DISCHARGE

Overall Treatment Plan Goal(s)/Objective(s) Achievement[See Summary of Treatment Outcomes & Results


 Minimal
 Moderate
 Treatment Plan Objectives Not Completed,
(From Treatment Plan)]
 Substantial
If Not completed please complete the following:

Client Referred to Another Level of Care

Client Transferred to Another Agency, explain reason for transfer: ___________________________
______________________________________________________________________________________
CLIENT: LAST NAME
FIRST
MI
ID#
PAGE 1 OF 4

Client Terminated Against Recommendation of Agency

Client Deceased: Provide explanation of circumstances: _________________________________
_____________________________________________________________________________________


Client Moved and Left No Forwarding Address or Contact Information

Client Unable to Participate Due to Loss of Abilities, explain loss: ________________________
 Other: _______________________________________________________________________
SUMMARY OF TREATMENT OUTCOMES AND RESULTS (From Treatment Plan)
Problem /Goal 1:
Objective 1a:
Objective 2b:
Objective 3c:
Objective 4d:
Current Progress on Objectives: _________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Problem /Goal 2:
Objective 1a:
Objective 2b:
Objective 3c:
Objective 4d:
Current Progress on Objectives: _________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Problem /Goal 3:
Objective 1a:
Objective 2b:
Objective 3c:
Objective 4d:
Current Progress on Objectives: _________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Problem /Goal 4:
Objective 1a:
Objective 2b:
Objective 3c:
Objective 4d:
Current Progress on Objectives: _________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
CLIENT: LAST NAME
FIRST
MI
ID#
PAGE 2 OF 4
OTHER GAINS BY CLIENT WHILE IN TREATMENT: _______________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
STATUS OF CLIENT AT DISCHARGE
Acute
Yes
No
If yes, explain why and any/all transition/referral/support services activated:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Chronic Yes
No
If chronic, is client currently stable? Yes
No If No, explain why and
any/all transition/referral/support services activated: _______________________________________________________
__________________________________________________________________________________________________
ASAM Placement at Discharge: ___________________________ (As applicable to treatment provided client)
Stage of Change at Discharge: _____________________________ (As applicable to treatment provided client)
MEDICATION SUMMARY
Name
Prescribing
of
Physician
Medication
Type
of
Medication
Dosage, Strength,
Frequency
of Medication
Efficacy
of
Medication
Length of time
on Medication
CONTINUING CARE / RELAPSE / REGRESSION PREVENTION /INTERVENTION PLAN:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Client Continues to Consent to Follow-Up
YES
NO
If No, why did client choose to rescind consent for Follow-Up? _____________________________________
___________________________________________________________________________________________
If Yes, when and how does client agree to be contacted for Follow-Up? 30 days  60 days 90 days

mailed questionnaire
telephone interview
in-person interview
Written Recommendations for Services and Supports; and, Specific Referrals for Implementing
Continuing Care Plan, including Medications: ___________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
CLIENT: LAST NAME
FIRST
MI
ID#
PAGE 3 OF 4
Special Circumstances of Client (if any): ________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Services Needed by Client as per Client and/or Representative (if any): _______________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
REFERRAL(S) (check all that apply)
 Inpatient Alcohol and Other Drug Services
 Case Management (Adult)
 Case Management (Child)
 Community Housing Program
 Domestic Violence Services
 Crisis Intervention Services
 Electronic or Virtual Services, i.e.: Neurofeedback
 Inpatient Mental/Behavioral Health Services
 Medical Services
 Medication Management Services, specify physician name: ___________________________________________
 Psychiatric Services, specify physician name: ______________________________________
 Legal Services (Juvenile Bureau, Legal Aid, etc.)
 Physical/Occupational Therapy
 Dietary Services
 Educational Services
 Systems of Care
 Advocacy Services, i.e.: NAMI
 Return to referral source
 Refer to primary physician
 Placement / Community Housing / Living Program or Services, i.e.: shelter, group home, home health, long-term
care, other, please specify: _________________________________________________________________________
 Support Groups / Self-help Groups, i.e.: AA / NA / ALA-NON, Parent Support Group, NAMI, please specify: _____
_______________________________________________________________________________________________
 Social/Protective Services, i.e.: DHS: TANF, Child Welfare, OJA, Adult Protective Services, Faith Based, Salvation
Army, Red Cross, please specify:
 Vocational Rehabilitative Services, i.e.: Physical/Occupational Therapy , Audio/Visual Svcs and/or Other VocRehab Service(s), please specify:
 Other, please specify: _____________________________________________________________________________
Contact Information for Referral Sources Selected: _____________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Summary Statement: ______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Person designated to track follow-up schedule after discharge:
______________________________________________________
Clinician Signature and Credentials
CLIENT: LAST NAME
CARF / ODMHSAS Draft #1 06/07
FIRST
Sheila Dickerman
________________________
Date
MI
ID#
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