BIRTH: / - / PROVIDER CLIENT ID: ADDRESS: CLIENT STREET ADDRESS 1: CLIENT STREET ADDRESS 2: CITY: STATE: ZIP CODE: ADMISSION: ADMISSION DATE: / / ADMISSION PROGRAM: DISCHARGE DISCHARGE DATE: / / DISCHARGE REASON: (check one box below) 41 AMA (AGAINST MEDICAL ADVICE) 30 AWOL FOR INPATIENT ONLY 40 CLIENT DISCONTINUED TX 32 DEATH DISCHARGED TO NEW SERVICE (FACILITY 51 CONCURS) 34 EVALUATION ONLY 36 INCARCERATED 38 IP DISCHARGE FOR IP MEDICAL TX 42 44 46 96 LEFT AGAINST ADVICE MOVED.
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How to fill out the CT DMHAS DDaP Discharge Form online
The CT DMHAS DDaP Discharge Form is an essential document for individuals transitioning from mental health and addiction treatment services. This guide will provide clear instructions on filling out the form accurately and efficiently online.
Follow the steps to complete the discharge form effortlessly.
- Click ‘Get Form’ button to access the discharge form and begin the process.
- Enter the client information section, including the client's full name, social security number, date of birth, provider client ID, and address.
- In the admission section, fill in the admission date and admission program details.
- Proceed to the discharge section by entering the discharge date and selecting the appropriate discharge reason by checking one box.
- On the diagnosis page, enter the effective date of diagnosis and list the client's clinical diagnoses under the respective axes (I, II, III). Provide the primary diagnosis and any additional diagnoses as needed.
- For Axis IV, indicate any psychosocial or environmental problems by selecting 'Yes' or 'No' for each item listed.
- Lastly, enter the Axis V GAF score, which should be a number between 0 and 100.
- After completing all sections, review the information for accuracy, and save your changes. You can then download, print, or share the completed form as necessary.
Complete your forms online today and ensure a smooth discharge process.
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