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Home
About Us
Team
Services
Resources
Patient Forms
Staff Forms/Trainings
Contact
- Patient Referral Form
- RFS Privacy Policy

Restoration Family Services Forms

“Helping families provide missing pieces”

Welcome to the Restoration Family Services, Inc.’s “Service Forms” platform.

Please fill in all required fields *:

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RFS DISCHARGE SUMMARY FORM

First Name*

Last Name*

Person Served Record Nr.*

Date Admitted*

Date Discharged*

Discharge from Service(s)* DWISAIOPSA GROUPOutpatient MH Therapy

Date of Last Billable Service*

REASON FOR DISCHARGE (please select the numbered item that applies):* 01 Death02 Refused Treatment03 Evaluation Complete04 Consistent No Shows05 Treatment Complete06 Svc Unavailable07 Client Not Available (moved)

Other:

REFERRED TO (please select the numbered item that applies):* 01 No referral02 Community SA/MH Agency03 Inpatient Treatment Facility04 Alcohol Tx Program05 Drug Tx Program06 Psychiatrist07 BHIS Program08 Social Services (DSS)09 Community Services10 Court/ Justice/ P.O.11 Vocational Rehab12 Veterans Administration13 MH/SA/DD Agency14 Clergy/Religious Organization15 General Hospital/Psychiatric Unit

Other:

Completed by:*

Date*

IF PERSON SERVED IS SEEN FOR 3 OR LESS VISITS, NARRATIVE DISCHARGE SUMMARY IS NOT REQUIRED

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DISCHARGE SUMMARY

IDENTIFYING INFORMATION:

Gender* MaleFemale

Date of Birth*

DIAGNOSIS (F-Code + Description):

F-Code/ Description

F-Code/ Description

F-Code/ Description

F-Code/ Description

REASON FOR ADMISSION:

PERSON SERVED NAME*

Date of Birth*

Person Served Abilities (ex. writing poems, singing)

Strength(s) (ex. family support)

Preference(s) (ex. female therapist)

Desired Outcome(s) (ex. “to stop drinking” or “to get my own place”)

TREATMENT SUMMARY:

RECOMMENDATIONS:

By signing, I am indicating that I have discussed or made attempts to discuss this discharge with the patient and I have discussed this discharge with the Clinical Supervisor.

Full Name*

Signature Date*

Please write your signature in the box below:*

Stand: 08/10/2022

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Restoration Family Services, Inc.
714 Wilkins Street • Smithfield, NC 27577
Phone: 1 919 938 9502
Fax: 1 919 938 9702
Email: rfs@restorethefamily.org
www.restorethefamily.org

CARF Accredited

CARF 3 year accreditation for Behavioral Health: Community Integration Respite Services, Alcohol & Drug Addictions, Mental Health Services & DWI Services

© Copyright 2020 Restoration Family Services, Inc. • All rights reserved. • Privacy Policy