DDAP-EFM-1007 12/15 Provider Location: Client Discharge Provider Name: (Required fields are in BOLD) DDAP License #: Name: M.I.: Last Name: Suffix: Admit Date: Discharge Date: Last Treatment Discharge Reason: Date: (Please Select) If Discharge Reason is by Facility” or to Other D&A Facility”, then answer the following: “Terminated “Transferred Did the client request an alternate provider referral? Yes No If yes, was an alternate referral made? Yes No Reason why client requested provider change? (Please Select) GENERAL Living Arrangement: (Please Select) Employment Detail not in Labor Force: Status: (Please Select) (Required if Employment Status is in Labor Force”) “Not No. of Client Arrests 30 Days Prior to Discharge: Frequency of self-help program attendance in the 30 days prior to discharge: (Please Select) SUBSTANCE ABUSE AT DISCHARGE PRIMARY DRUG Substance Frequency: Abused: (Please Select) (Please Select) SECONDARY DRUG Substance Abused: Frequency: (Please Select) (Please Select) TERTIARY DRUG Substance Abused: Frequency: (Please Select) (Please Select) Additional Information: Form to be submitted to SCA if required by the SCA for case management purposes. INFORMATION MUST BE RETAINED BY THE PROVIDER FOR FEDERAL REPORTING
DDAP-EFM-1007 12/15 Client Discharge (Required fields are in BOLD) Provider Location: Provider Name: DDAP License #: Name: M.I.: Last Name: Suffix: Admit Date: Discharge Date: Last Treatment Date: Discharge Reason: (Please Select) If Discharge Reason is “Terminated by Facility” or “Transferred to Other D&A Facility”, then answer the following: Did the client request an alternate provider referral? Yes No If yes, was an alternate referral made? Yes No Reason why client requested provider change? (Please Select) GENERAL Living Arrangement: (Please Select) Employment Status: Detail not in Labor Force: (Please Select) (Required if Employment Status is “Not in Labor Force”) No. of Client Arrests 30 Days Prior to Discharge: Frequency of self-help program attendance in the 30 days prior to discharge: (Please Select) SUBSTANCE ABUSE AT DISCHARGE PRIMARY DRUG Substance Abused: Frequency: (Please Select) (Please Select) SECONDARY DRUG Substance Abused: Frequency: (Please Select) (Please Select) TERTIARY DRUG Substance Abused: Frequency: (Please Select) (Please Select) Additional Information: Form to be submitted to SCA if required by the SCA for case management purposes. INFORMATION MUST BE RETAINED BY THE PROVIDER FOR FEDERAL REPORTING
DDAP-EFM-1007%20-%20Client%20Discharge.docx