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Discharge Date:
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Type of Service: Mental Health
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Primary Discharge DSM-5 Diagnosis:
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Discharge Condition:
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Type of Discharge:
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Discharge Reasons: (Check all that apply)
• • •
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Current Risk Assessment:
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Patient’s Risk to Self:
• • •
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Patient’s Risk to Others:
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Current Impairments:
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Mood Disturbance (Depression or Mania):
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Anxiety:
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Psychosis/Hallucinations/Delusions:
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Thinking/Cognition/Memory/Concentration Problems:
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Impulsive/Reckless/Aggressive Behaviors:
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Activities of Daily Living Problems:
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Weight Change Associate with a Behavioral Diagnosis:
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Medical/Physical Condition:
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Substance Abuse/Dependence:
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Job/School Performance Problems:
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Social/Relationship/Marital/Family/Sexual Problems:
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Legal Problems:
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Provider
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Date:
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