Path Program Discharge Summary

ADVERTISEMENT

Enclosure 24
FY 2013-14
PATH Program Discharge Summary
Client Name: ______________________________________________________________
Discharged to: _____________________________________________________________
Address: _________________________________________________________________
Phone: ___________________________________________________________________
Enrollment Date: _________________
Discharge Date: _______________
Type of Discharge:
Low Impact
(Dropped Out, Refused Service, Lost Contact)
Medium Impact
(Remains Homeless but Linked to Mental Health Services)
High Impact
(Temporarily or Permanently Housed and Linked to Mental Health Services)
HOUSING STATUS UPON DISCHARGE
1. Homeless:
Outdoors
Abandoned Building
Short-Term Shelter
Unknown
2. Temporary Housing:
Long-Term Shelter
Homeless Service Center
Transitional Housing (up to 24 months)
Motel
Residential Treatment Program
Living with Family/Friends
3. Permanent Housing:
Supportive Housing Program
Shelter + Care
Section 8 Voucher
Leases Own Apartment/Room/House
Other ______________________________________________
4. Corrections or Institution:
Jail or Correctional Facility
Hospital
Nursing Home
Was Client’s Housing Status Improved from Initial Contact to Discharge?
YES
NO
Outcome Measures
OBTAINED FOLLOWING SERVICES AND RESOURCES DURING ENROLLMENT: Check
Housing (temporary, transitional, permanent)
Assisted
Attained
Mental Health Services
Assisted
Attained
Income Benefits (SSI/SSDI)
Assisted
Attained
Employment
Assisted
Attained
N/A
Medical Insurance or Coverage Plan
Assisted
Attained
N/A
Additional Services
General Assistance Income
California ID
Self Help (i.e. 12 step programs)
Dental Services
VA Benefits
Primary Health Care
CalFresh Program/ Food Stamps
TANF
Substance Abuse Services
Other _____________________________________________
DISCHARGE SUMMARY Comments:
_________________________________________________________________________________________
_
PATH Staff Name (Print): _____________________________________________ Date: ________________
:______________________________________
PATH Staff Name (Signature)
PATH 2013-14 Request for Application
Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Discharge Summary General Format Discharge Summary General Format Business
Discharge Summary Samples Discharge Summary Samples Business
Form Hud-92045 Multifamily Housing Assisted Living Conversion Program Application Summary Sheet Form Hud-92045 Multifamily Housing Assisted Living Conversion Program Application Summary Sheet Legal
Dd Form 2884 - Dod Youth Program Annual Summary Of Operations Dd Form 2884 - Dod Youth Program Annual Summary Of Operations Business
Dd Form 2605 - Department Of Defense Child Development Program Annual Summary Of Operations Dd Form 2605 - Department Of Defense Child Development Program Annual Summary Of Operations Business
Dd Form 2646 - Department Of Defense School-age Care (sac) Program Annual Summary Of Operations Dd Form 2646 - Department Of Defense School-age Care (sac) Program Annual Summary Of Operations Business
Program Summary Report - West Virginia Securities Commission Program Summary Report - West Virginia Securities Commission Legal
Summary Of The Uniform Crime Reporting Program - Section I - Federal Bureau Of Investigation Summary Of The Uniform Crime Reporting Program - Section I - Federal Bureau Of Investigation Legal
Path To Success Monthly Contact Sheet (mcs) - Larimer County Workforce Center Path To Success Monthly Contact Sheet (mcs) - Larimer County Workforce Center Business
Discharge Of Debtor After Completion Of Chapter 13 Plan Discharge Of Debtor After Completion Of Chapter 13 Plan Financial

Related Categories

Parent category: Business
Download
Go
Page of 2