D4.7_Discharge Form.doc

DOC document 185 KB Posted Aug 26, 2026

Attached to: G004--Transitional Housing Services for VAGLAHS 30 Bed Low Demand Safe Haven SPA 5
Solicitation number: 36C26226R0083
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 22

About this file

Written by GovTribe AI · Aug 26, 2026

This is a Residential Treatment Exit Form Worksheet used to document Veterans' discharge from VA residential treatment programs, including Grant and Per Diem (GPD) programs, HCHV Contract Residential Treatment Programs, and HCHV Low Demand Safe Haven facilities. The form captures comprehensive data on Veteran outcomes upon program exit, including demographic information, length of stay, billable days and cost of care, and the reason for program termination (successful completion, rule violation, incarceration, death, or voluntary departure). The worksheet documents post-exit housing arrangements across 26 housing categories ranging from owned or rented housing with or without subsidies to emergency shelters and places not meant for habitation, along with housing stability assessment, living arrangements, and employment status at exit.

The form also systematically collects detailed information on Veterans' financial situations, including cash income sources from employment, VA disability compensation, Social Security, SSI, SSDI, and other benefit programs, as well as non-cash benefits such as Medicaid, Medicare, SNAP, and TANF received in the 30 days prior to exit. Additionally, it documents clinical treatment arrangements for ongoing issues including alcohol problems, drug problems, mental health conditions, medical problems, social and recreational deficits, and vocational skill deficits, specifying whether treatment was arranged with VA providers, non-VA providers, or both. The form includes sections for recording referrals for unresolved issues, active provider involvement, and a transitional plan utilizing the SNAP framework (Strengths, Needs, Abilities, Preferences) to support continued recovery and community support.

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Other files

File	Type	Posted
36C26226R0083 0001_1.docx	DOCX document	Sep 23, 2026
D4.8_Quality Assurance Surveillance Plan.docx	DOCX document	Aug 26, 2026
D4.6_Admission Referral Tracker Spreadsheet.xlsx	XLSX spreadsheet	Aug 26, 2026
D4.4_Request for Extension of Per Diem Form.docx	DOCX document	Aug 26, 2026
D4.5_SQUARES.pdf	PDF	Aug 26, 2026
D.4.2_Contractor Rules of Behavior Agreement Form.pdf	PDF	Aug 26, 2026
D.4.3_Incident Reports.docx	DOCX document	Aug 26, 2026
D.4.1_Americans with Disabilities Act.pdf	PDF	Aug 26, 2026
36C26226R0083_Transitional Housing 30 Bed LDSH SPA.pdf	PDF	Aug 26, 2026

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Residential Treatment Exit Form Worksheet

Use this form to document exit of Veterans from a Grant and Per Diem program (GPD), HCHV Contract Residential Treatment Program, and HCHV Low Demand Safe Haven.

Staff member completing this form (first and last name) ..………

VA Site (3-digit VAMC code plus 2-digit suffix, if any) ………….

__6__ __9__ _1___ ____ ____

Date this form completed (mm/dd/yy)……………..…...……...…

____ ____ / ____ ____ / ____ ____

I. Veteran Information

Veteran’s name (last name, first initial)……………….……………

Social Security number………………...……….……………..…..

____ ____ ____ - ____ ____ - ____ ____ ____ ____

Date of birth (mm/dd/yy)……………………………………………

____ ____ / ____ ____ / ____ ____

II. Residential Treatment Stay

Program Type ………………………….……………….……………

Project Code ………..………………….……………….……………

Program Name …..…………………….……………….……………

Period covered by this report

(Code dates: mm/dd/yy) Entry date:

Exit date:

1a. Billable Days (LOS) and Cost of Care (to be completed for GPD, HCHV, DCHV)

Unpaid days:

__ __ __

Billable days (LOS):

__ __ __ __ __

Cost of treatment (round to nearest dollar):

$__ __ , __ __ __

III. Status at Program Exit

The Veteran ended residential treatment because:

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1. Successful completion of the program

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2. Successfully completed some components of the program

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3. Veteran was asked to leave because of violation of program rules or failure to comply with program requirements

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4. Veteran required a more intensive level of care than offered at this program

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5. Veteran was transferred to another residential program for administrative reasons

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6. *Veteran left the program by his/her own decision, without consulting staff

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7. Veteran was incarcerated

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8. Veteran is deceased

*For AWOL Veterans, program staff must attempt to locate the veteran prior to forwarding & officially discharging them.

If item 2 = 8 (Veteran is deceased), do not complete the remainder of the form

2a.

If the Veteran ended residential treatment because of a rule violation, what was the most important reason?

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1. Threatened/actual violence to self or others (exclusion)

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2. Use of alcohol or drugs

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3. Curfew violation

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4. Other (please specify) __________________________________________

What is the Veteran’s housing arrangement at program exit (location where the Veteran was sleeping on the night of program exit) ?

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1. Housing owned by Veteran, no ongoing housing subsidy

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2. Housing owned by Veteran, with ongoing housing subsidy

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3. Housing rented by Veteran, no ongoing housing subsidy

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4. Housing rented by Veteran with HUD-VASH voucher

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5. Housing rented by Veteran with non-HUD-VASH housing subsidy

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6. Permanent housing for formerly homeless persons (such as SHP, S+C, or SRO MOD Rehab)

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7. Staying or living with family, permanent tenure

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8. Staying or living with family, temporary tenure

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9. Staying or living with friends, permanent tenure

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10. Staying or living with friends, temporary tenure

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11. GPD transitional housing

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12. Non-VA transitional housing for homeless persons

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13. VA MH RRTP

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14. CWT/TR

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15. Non-VA residential treatment program

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16. Non-VA residential substance abuse treatment facility or detox center

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17. Hospital or other residential non-psychiatric medical facility

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18. Long-term care facility or nursing home

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19. Psychiatric hospital or other psychiatric facility

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20. Prison or jail

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21. VA contracted residential treatment programs (HCHV Contract Residential Services)

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22. Safe Haven (SH

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23. Hotel or motel paid for without emergency shelter voucher

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24. Emergency Shelter (ES), including hotel or motel paid for with emergency shelter voucher

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25. Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station or anywhere outside)

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26. Don’t know

Specify subsidy type:

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1. Mainstream (non-HUD-VASH) Housing Choice Voucher

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2. Public Housing Unit, such as housing fully funded or subsidized by HUD

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3. SSVF Rapid Rehousing (RRH) or equivalent RRH subsidy

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4. Other subsidized housing, including locally-funded subsidized housing

What is the zip code of that location? Code N in 1st space if unknown.

____ ____ ____ ____ ____

Full Address:

Phone Number:

4a. In which CoC will the Veteran be residing at the time of program exit (if unknown, use current location)?

Los Angeles City & County CoC

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Santa Maria/Santa Barbara County CoC

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Bakersfield/Kern County CoC

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Pasadena CoC

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Oxnard, San Buenaventura/Ventura County CoC

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Glendale CoC

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San Luis Obispo County CoC

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Veteran will be residing in a CoC outside the VAMC catchment area.

Housing stability: How would you describe the Veteran’s housing situation at program exit?

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1. Literally homeless

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2. Imminent risk of losing housing

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3. Unstably housed/at risk of losing housing

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4. Stably housed

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5. Don’t know

With whom will the Veteran be living at program exit?

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0. No residence

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1. Alone

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2. With spouse/partner or children

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3. With parents, with siblings, or with other family

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4. With friends

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5. With strangers

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6. Don’t know

What is the Veteran’s arrangement for employment at program exit?

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0. Disabled or retired

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1. Unemployed

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2. Actively seeking employment

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3. Part-time or temporary employment

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4. Full-time employment

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5. VA’s IT or CWT (VI) (NOTE: include CWT/TW only. IPS/SE and CBSE are considered employment.)

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6. Other vocational training

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7. Unpaid volunteer

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8. Student

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9. Don’t know

What is the Veteran’s arrangement for receipt of VA financial benefits (disability payments or pension) at the time of program exit?

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0. Currently receiving VA benefits and will continue

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1. Has pending application for VA financial benefits

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2. Is planning to apply for VA financial benefits

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3. Is neither receiving nor planning to apply for any VA financial benefits

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4. Do not know Veteran’s status with respect to VA financial benefits

What is the Veteran’s arrangement for receipt of non-VA financial benefits (disability payments or other support) at the time of program exit?

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0. Currently receiving non-VA benefits and will continue

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1. Has pending application for non-VA financial benefits

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2. Is planning to apply for non-VA financial benefits

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3. Is neither receiving nor planning to apply for any non-VA financial benefits

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4. Do not know Veteran’s status with respect to non-VA financial benefits

10.

Did the Veteran receive any money in the 30 days prior to program exit?

If 10 = no or Case manager omitted item, skip to item 11

If 10 = yes, list the average monthly amount in each category

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0= No

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1=Yes

99= Case manager omitted item

Please round to whole dollar amounts and note comma placement (eg., $452.76 should be entered as $ _ _,453.00 )

a. Employment (include CWT/SE)

$ ___ ___ , ___ ___ ___ . 0 0

b. Compensation for service connected psychiatric condition

$ ___ ___ , ___ ___ ___ . 0 0

c. Compensation for other service connected condition

$ ___ ___ , ___ ___ ___ . 0 0

d. Non-service connected pension

$ ___ ___ , ___ ___ ___ . 0 0

e. Retirement income from Social Security

$ ___ ___ , ___ ___ ___ . 0 0

f. Pension from a former job

$ ___ ___ , ___ ___ ___ . 0 0

g. Supplemental Security Income (SSI)

$ ___ ___ , ___ ___ ___ . 0 0

h. Social Security Disability Income (SSDI)

$ ___ ___ , ___ ___ ___ . 0 0

i. Private disability insurance

$ ___ ___ , ___ ___ ___ . 0 0

j. Worker’s compensation

$ ___ ___ , ___ ___ ___ . 0 0

k. Unemployment insurance

$ ___ ___ , ___ ___ ___ . 0 0

l. Temporary Assistance for Needy Families (TANF) or similar local program

$ ___ ___ , ___ ___ ___ . 0 0

m. General Assistance (GA) or similar local program

$ ___ ___ , ___ ___ ___ . 0 0

n. Child support

$ ___ ___ , ___ ___ ___ . 0 0

o. Alimony or other spousal support

$ ___ ___ , ___ ___ ___ . 0 0

p. All other sources (do not include food stamps)

$ ___ ___ , ___ ___ ___ . 0 0

Total Amount

[Total income calculated in HOMES].

11.

Did the Veteran receive any non-cash benefits in the 30 days prior to program exit?

If 11 = no or Case Manager omitted item, skip to item 12

If 11 = yes, indicate type(s) of benefits received

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0= No

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1=Yes

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99= Case manager omitted item

a. Medicaid health insurance program or similar local program

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0= No FORMCHECKBOX 1=Yes

b. Medicare health insurance program or similar local program

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0= No FORMCHECKBOX 1=Yes

c. Temporary Rental Assistance

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0= No FORMCHECKBOX 1=Yes

d. Homeless Prevention and Rapid Re-housing Program (HPRP) Funds

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0= No FORMCHECKBOX 1=Yes

e. Veteran Service Organizations

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0= No FORMCHECKBOX 1=Yes

f. State Children’s Health Insurance Program or similar local program

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0= No FORMCHECKBOX 1=Yes

g. Supplemental Nutrition Assistance Program (SNAP) or Food Stamps

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0= No FORMCHECKBOX 1=Yes

h. Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

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0= No FORMCHECKBOX 1=Yes

i. Temporary Assistance for Needy Families (TANF) or similar local program Child Care Services

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0= No FORMCHECKBOX 1=Yes

j. Temporary Assistance for Needy Families (TANF) or similar local program Transportation Services

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0= No FORMCHECKBOX 1=Yes

k. Other TANF-funded services

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0= No FORMCHECKBOX 1=Yes

l. Bus, subway, train or cab voucher

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0= No FORMCHECKBOX 1=Yes

m. Other

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0= No FORMCHECKBOX 1=Yes

SNAP:

Strengths:

Needs:

Abilities:

Preferences:

Transitional Plan:

1. List of referrals for on-going unresolved issues.

2. List of providers with whom the Veteran is involved (VA and community).

3. Progress & Community Support towards recovery:

IV. Follow-up Arrangements

Select the code that best describes clinical treatment arrangements made at program exit.

12.

Alcohol problems

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0. Not a problem area for this veteran

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1. Problem area for this Veteran, but no treatment arranged

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2. Veteran’s treatment has been arranged with non-VA provider

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3. Veteran’s treatment has been arranged with VA provider

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4. Veteran’s treatment has been arranged with both non-VA and VA provider

13.

Drug problems

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0. Not a problem area for this veteran

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1. Problem area for this Veteran, but no treatment arranged

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2. Veteran’s treatment has been arranged with non-VA provider

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3. Veteran’s treatment has been arranged with VA provider

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4. Veteran’s treatment has been arranged with both non-VA and VA provider

14.

Mental health problems (other than drug or alcohol)

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0. Not a problem area for this veteran

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1. Problem area for this Veteran, but no treatment arranged

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2. Veteran’s treatment has been arranged with non-VA provider

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3. Veteran’s treatment has been arranged with VA provider

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4. Veteran’s treatment has been arranged with both non-VA and VA provider

15.

Medical problems

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0. Not a problem area for this veteran

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1. Problem area for this Veteran, but no treatment arranged

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2. Veteran’s treatment has been arranged with non-VA provider

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3. Veteran’s treatment has been arranged with VA provider

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4. Veteran’s treatment has been arranged with both non-VA and VA provider

16.

Social and recreational deficits

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0. Not a problem area for this veteran

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1. Problem area for this Veteran, but no treatment arranged

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2. Veteran’s treatment has been arranged with non-VA provider

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3. Veteran’s treatment has been arranged with VA provider

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4. Veteran’s treatment has been arranged with both non-VA and VA provider

17.

Vocational skill deficits

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0. Not a problem area for this veteran

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1. Problem area for this Veteran, but no treatment arranged

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2. Veteran’s treatment has been arranged with non-VA provider

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3. Veteran’s treatment has been arranged with VA provider

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4. Veteran’s treatment has been arranged with both non-VA and VA provider

File details come from the government source that posted it. Updated Aug 26, 2026.