Client Name, DOB: self explanatory

Rating: Use the following scale to rate the success of services:

1= NO SUCCESS: At the time that services were discontinued, the problems still happened as much as they did before we started services.

2=LOW SUCCESS: At the time that services were discontinued, the problems had improved a little and parent/client learned a little about what to do to make things better, but there were still a lot of problems.

3=MODERATE SUCCESS: At the time that services were discontinued, the problems had improved a lot and parent/client had learned what to do to make things better, but treatment plan goals had not been met or parents were still not entirely consistent at follow through.

4=HIGH SUCCESS: At the time that services were discontinued, the problems were down to a manageable level and parent/client felt confident about what to do to maintain gains.

Status: check the box that fits the client’s current legal status

Discharge Review Activities:

  1. Review Period: This should be the intake date until the date that you decided to discharge the case (e.g., 2 weeks after Unable to Reach Letter Sent, 2nd month without Medicaid reinstated). For administrative discharges, this should be at least 3 weeks after the last session date.
  2. Written by: This is you, the Primary Clinician
  3. Developed with input from: Indicate who was present for the discussion of the review or made suggestions for the aftercare plan as part of its development.
  4. Notation of discussions: This is a very brief summary of the input from those on the treatment team. For unsigned discharges, just write N/A.Examples: All agreed that progress was made and no further treatment is necessary, Parent too busy to commit to services at this time, Client moving and will seek services after move.
  5. Notified case manager of discharge plan: If client has a TCM (targeted case manager), DCM (dependency case manager), DJJ probation officer. school contact who manages school referrals, or any other person serving in a case management capacity (usually the referral source), they have to be notified that services have been terminated. Write “Yes” if you notified them or N/A if the client does not have a case manager.
  6. Attachments: N/A for cases not seen in >3 weeks.

*For signed discharges, the following are required: Consumer Satisfaction Survey and Consumer Discharge Rating (completed by the client/parent and given back to you in a sealed envelope) and CFARS/FARS.

*Even for unsigned discharges, if less than 3 weeks from last session until decision to discharge, CFARS/FARS is required.

Most Recent Diagnoses: List the names (not ICD codes) of the Axis I, II, III, and IV diagnoses from the LE, or the most recent one if changed on a TPR. The intake GAF is from the Bio-Psychosocial. The DC GAF is based on current client functioning. Progress (DC rating >1) should be reflected in a higher DC GAF.

Summary of Services Provided:

  1. Clinician Name: Write your name and any other clinicians who shared the case with you or transferred the case to you
  2. 1st Session/Last/Months: List the intake date, the last session date, and the length of treatment in whole months (e.g., rounded up if 15 days, down if <14)
  3. Participants: check or write in everyone who participated in services (e.g., mother, father, grandmother, teacher)
  4. Description of individual intervention: Briefly describe the treatment strategies provided in individual sessions with the client.
  5. Description of family/community interventions: Briefly describe the treatment strategies provided in sessions with parents/caregivers/teachers.

Client Findings/Progress:

  1. Problem #1-4: Name the problem title and report the measurable progress since intake on each problem from the Treatment Plan. This is a change statement, so it should compare baseline amount of the problem to current amount. Be sure to include all Treatment Plan Problems, using the same title and order as on the Treatment Plan. Examples: Noncompliance reduced from 100% at intake to 50% in final week, Depression remained the same as at intake with a rating of 8 on a 10-point scale, Angry outbursts decreased from multiple times daily at intake to 2 times in final week.
  2. Findings: Cite the reasons for progress of lack thereof. Examples: great progress due to parent and client motivation and follow through with strategies, change in family structure (mother’s boyfriend moved in) resulted in increase in client’s behavior, mother has had difficulty being consistent with parenting strategies, father was in hospital so client had to move to aunt’s home temporarily, mother had a new baby and reduced attention to client

Conclusions/Recommendations: At least one of the items must be checked to indicate changes in the Treatment Plan in order for the DC to be billable

a.Conclusion: check the box that describes the reason for termination of services. Write in the reason for administrative discharge (e.g., failure to respond to Unable to Reach letter, parent failed to reactivate funding after 2 months) or “other.”

b.Recommended Aftercare Plan: This section is on a separate form, called the Discharge Aftercare Plan. It must be attached to the Discharge Review. For planned discharges, bring 2 Aftercare plan forms, to give one to the client/caregiver. For administrative discharges, the office will mail a copy of the Aftercare Plan to the client/caregiver.

*If client is already receiving and should continue services from another provider (e.g., medication management, case management, tutoring, mentoring, self-help groups, support groups, job coaching, substance abuse treatment), indicate the type of service and provider.

*If the client needs services that are not already being provided, be sure to include the contact information for these services.

*If the case is closed due to lack of funding but they are willing to have services elsewhere, it is imperative that you give them referral information for another agency that has indigent funding. Agencies that serve the indigent population are listed on the Aftercare Form (form is available in Spanish for clients/caregivers who do not read English).

Effective Date: Leave this line blank. The plan becomes effective when Sharon signs it, and you don’t know what that date will be.

Signature lines: Only DC Reviews signed by the client and guardian are billable.

  1. All clients, even those who are minors, sign the Treatment Plan as evidence that they participated in the development of their plan. If they cannot sign, write “unable to sign due to age” (can only be used for clients who are not yet in school) or “unable to sign due to disability” (e.g., mental retardation, Autism, spasticity, paraplegia).
  2. For all clients who are under age 18, their legal guardian must sign. This is usually the parent/relative/non-relative caregiver that they are living with. Ask to make sure they are the legal guardian before they sign.
  3. For children in a licensed foster home, the Dependency Case Manager (DCM) must sign as the legal guardian. If you are not able to get the DCM signature in person, include a fax cover sheet with the name, agency, phone number, and fax number of the DCM when you turn in your Treatment plan, so that the Compliance Specialist can fax it to get the signature for you.
  4. The “Other participant/relationship” signature line is required if there are other people who will be included in treatment sessions. Be sure to indicate that person’s relationship to the client. This can be a second parent, other caregiver involved in treatment, a foster parent, a parent of an adult client if the parent is going to be involved in treatment, a teacher if involved in treatment, etc. All participants involved in the development of the plan need to sign it.
  5. Be sure to leave the signature line for the Treating Practitioner (in the box with the certification statement) blank for Sharon to sign.

Adapt Behavioral Services – Clinician Procedure ManualDischargeReview Instructions – Revised 03/13