CM-EA Discharge Form



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Completion Status(Required)
Discharge Reason(Required)
Was client satisfied with experience in treatment?(Required)
Did client demonstrate improvement in school / work attendance?(Required)
Did client demonstrate improvement in school / work performance?(Required)
Client had no new criminal offenses during treatment.(Required)
Client had no new charges for drug-related offenses.(Required)
Client was involved in prosocial activities at discharge.(Required)
Client had a history of marijuana/THC use.(Required)
IF YES, at discharge client demonstrated:
Client had a history of other drug use (excluding marijuana).(Required)
IF YES, at discharge client demonstrated:
Client was drug-free at discharge.(Required)
Did you provide drug screens?(Required)

Review Intake Form

Gender(Required)

Ethnicity(Required)
Primary Race(Required)

Secondary Race - If Biracial Select One

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Would this emerging adult have been moved to restrictive placement if they were not accepted to participate in this program?(Required)
Primary Referral Source(Required)

Risk Factors - Check All That Apply(Required)
Primary Substance Used(Required)

Previous Treatment - Check All That Apply(Required)
Living Arrangement(Required)