36C24218R0338-005.pdf

VISN 2 HCHV Contract Residential– Discharge Summary

Client Name:

Intake Date: Discharge Date:

Exit Destination (Address/Program):

1. Was client able to take care of personal hygiene? Yes No Comments:

2. Did client participate in residence activities (house meetings, goal planning, etc.)? Yes No

3. Did client respond positively to Case Management? Yes No

4. Did client participate in any social/vocational activities (AA/NA meetings, church, employment groups, etc.) while residing in shelter? Yes No

5. Please select from the below that best describes the Veteran’s housing status upon discharge:

Having one’s own apartment, room or house Halfway House/Institution/other residential level of care None Unknown/Other

Staff Signature: __________________________________ Date: ___________________

Client Signature: _________________________________ Date: ___________________