State of Montana Children’s Mental Health Bureau Discharge Notification Form-Form #005 Revised October 2017 Therapeutic Group Home (TGH) Home Support Services (HSS) Form must be submitted within 5 business days of discharge Please type or print clearly. Processing may be delayed if information submitted is illegible or incomplete. Youth Information NAME: ADDRESS: CITY: STATE: ZIP: COUNTY: SSN: DOB: NUMBER: REASON FOR DISCHARGE: NO LONGER MEETS CRITERIA LOC – – – NOT OUT OTHER: – Custodian/Guardian Information Name: Phone Number: ADDRESS: CITY: STATE: ZIP: CUSTODIAN/GUARDIAN: PARENT/LEGAL GUARDIAN TRIBAL SOCIAL SERVICES/BIA TURNED 18 OTHER: 6 CFSD 6 Discharging Provider Information PROVIDER NAME: NAME OF PERSON SUBMITTING FORM: PHONE TODAY’S DATE (MM/DD/CCYY): DISCHARGED TO: ) OF PHONE NUMBER: DATE OF ADMISSION DATE DISCHARGE (MM/DD/CCYY): Transmit forms to: CMHB by fax at 406-444-6864 OR by the state’s at https://transfer.mt.gov/ to OR mail to Children’s Mental Health Bureau, PO Box 4210, Helena, MT 59601 DO SEND THROUGH REGULAR E-MAIL AS IT IS NOT SECURE.
State of Montana Children’s Mental Health Bureau Discharge Notification Form-Form #005 Revised October 2017 Therapeutic Group Home (TGH) Home Support Services (HSS) Form must be submitted within 5 business days of discharge Please type or print clearly. Processing may be delayed if information submitted is illegible or incomplete. Youth Information NAME: ADDRESS: CITY: STATE: ZIP: COUNTY: SSN: DOB: REASON FOR DISCHARGE: – LOC – – NO LONGER MEETS CRITERIA – OUT OTHER: Custodian/Guardian Information Name: Phone Number: ADDRESS: CITY: STATE: ZIP: CUSTODIAN/GUARDIAN: PARENT/LEGAL GUARDIAN TRIBAL SOCIAL SERVICES/BIA TURNED 18 OTHER: 6 CFSD 6 Discharging Provider Information PROVIDER NAME: NAME OF PERSON SUBMITTING FORM: PHONE NUMBER: TODAY’S DATE DISCHARGED TO: ) PHONE NUMBER: DATE OF ADMISSION (MM/DD/CCYY): DATE OF DISCHARGE (MM/DD/CCYY): Transmit forms to: CMHB by fax at 406-444-6864 OR by the state’s at https://transfer.mt.gov/ to OR mail to Children’s Mental Health Bureau, PO Box 4210, Helena, MT 59601 DO NOT SEND THROUGH REGULAR E-MAIL AS IT IS NOT SECURE.
DischargeNotificationTGHHSSOct2017.docx