CM-YA Discharge Form PROVIDER MENUPROVIDER MENUDashboardNewsLinkseLibrary CM-YA eLibraryCM-EA eLibraryCM-A eLibraryCM-PO eLibraryFavorites Account Change PasswordLogout Provider Name(Required) Agency Client ID(Required) Agency Name(Required) Discharge Date(Required) MM slash DD slash YYYY Completion Status(Required) Treatment Completed with ALL GOALS MET and Sustainable Treatment Completed with MAJORITY OF GOALS MET and Sustainable The Majority of Goals WERE NOT MET and Sustainable Discharge Reason(Required) HIGHER LEVEL OF CARE NEEDED: Client was placed in a restrictive setting (detention center, residential placement) [due to an event or offense that occurred during treatment] and placement lasted for a duration of time that precluded further treatment. MUTUALLY INITIATED ENDING: Provider and client mutually agreed that further progress was unlikely at this point and treatment would end though not all treatment goals were met or are not all sustainable (“diminishing returns”). PROVIDER DIRECTED ENDING: Provider decision to discharge the client for reasons other than #7. CLIENT INDIRECT ENDING: Even though outcomes were not positive, decision to discharge client because provider was not able to engage the client in treatment, despite persistence on the provider’s part to engage and align with the client. CLIENT EXPLICIT ENDING: Decision to discharge due to client stated desire to end or stated lack of willingness to continue, even though outcomes were not positive. MOVED: The youth/family moved out of the provider’s service area. FUNDING / REFERRAL SOURCE ADMINISTRATIVE REMOVAL / WITHDRAWAL: Youth was removed from the program by the funding or referral source due to administrative issues or decisions unrelated to the progress of treatment. PROGRAM ADMINISTRATIVE REMOVAL / WITHDRAWAL: Youth was removed from the program by the program administration due to administrative issues or decisions unrelated to the progress of treatment. RESTRICTIVE PLACEMENT, PRIOR EVENT: Youth was placed in a restrictive setting (detention center, residential placement) [due to an event or offense that occurred prior to the beginning of treatment] and placement lasted for a duration of time that precluded treatment. TREATMENT COMPLETED BASED ON POSITIVE OUTCOME: The client was discharged based on the mutual agreement of the team and client due to positive outcomes. Was client satisfied with experience in treatment?(Required) Yes No Was parent / caregiver satisfied with their experience in treatment?(Required) Yes Partially No N/A Client Satisfaction Questionnaire (CSQ-3) Score Question #1(Required)Client Satisfaction Questionnaire (CSQ-3) Score Question #2(Required)Client Satisfaction Questionnaire (CSQ-3) Score Question #3(Required)Did client demonstrate improvement in school / work attendance?(Required) Yes No N/A Did client demonstrate improvement in school / work performance?(Required) Yes No N/A Client had no new criminal offenses during treatment.(Required) Yes No N/A Client was involved in prosocial activities at discharge.(Required) Yes No Caregiver demonstrated improved monitoring and supervision.(Required) Yes No Evidence of reduced family conflict(Required) Yes No Client was drug-free at discharge.(Required) Yes No Number of Sessions(Required)Did you provide drug screens?(Required) Yes No Number of drug screens administered:Number of NEGATIVE drug screens:Number of POSITIVE drug screens:Review Intake FormClient Age(Required)Gender(Required) Male Female Other Ethnicity(Required) NOT Hispanic or Latino Hispanic or Latino Primary Race(Required) Black or African-American White Asian American Indian or Alaskan Native Pacific Islander Other Secondary Race - If Biracial Select One Black or African-American White Asian American Indian or Alaskan Native Pacific Islander Other First Session Date(Required) MM slash DD slash YYYY Referral Date(Required) MM slash DD slash YYYY Would this youth have been placed out of home if they were not accepted to participate in this program?(Required) Yes No Primary Referral Source(Required) Probation Parole Social Services / Child Protection Mental Health Substance Abuse Agency Court School Police Family Self Other Risk Factors - Check All That Apply(Required) Poor School Performance Poor School Attendance Substance Use Substance Dependence Other Criminal Behavior Mental Health Condition / Disorder Negative Peers Parent Substance Abuse Parent Mental Health Condition / Disorder Parent Incarceration Family Conflict Low Parental Monitoring / Supervision Low Involvement in Prosocial Activities Primary Substance Used(Required) Alcohol Marijuana or other cannabis product Other Previous Treatment - Check All That Apply(Required) None Individual Therapy Family Therapy Outpatient Drug / Alcohol Treatment Inpatient Drug / Alcohol Treatment Outpatient Psychiatric Inpatient Psychiatric Other Residential Treatment Foster Care Alcoholics Anonymous Narcotics Anonymous Living Arrangement(Required) Both Parents Mother Only Father Only Relative Father / Stepmother Mother / Stepfather Mother / Paramour Father / Paramour Foster Parents Other Legal Guardian Living Independently
