Fiona Dava 3

Client Name: Click or tap here to enter text.

Date of Birth: [MM/DD/YYYY]

Date of Admission: [MM/DD/YYYY]

Date of Discharge: [MM/DD/YYYY]

Presenting Problem Upon Admission: [State the client's presenting problem upon admission. What behaviors would indicate that the client is sustaining at a healthy baseline or the presenting problems are no longer an issue?]

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Current Medication: [List the client's current medications, if applicable.]

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Reason for Discharge: [State the client's reason for discharge. How did you determine if Eliza met her treatment goals?]

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Resources and Referrals: [List the client's resources and referrals. Based on your assessment of current symptomology, does your client, Eliza, need wraparound services, outpatient references, and/or step-down services?]

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Projected Prognosis: [State the client's projected prognosis.]

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Eliza D 00/00/00

<sign and date here>

Client Signature & Date

Counselor’s Signature & Date