AFTERCARE PLAN SUMMARY AND DISCHARGE FORM002 INSTRUCTIONS002 SECTION 1 Patient Name must be entered as follows: last name, first name, middle initial. State facility must be a State Mental Hospital name or a State Restoration Center name. Patient222s 2 digit PCIS Discharge Code must be indicated. Discharge Address must consist of a complete mailing address with a zip code. Telephone number must include area code. Case number at State facility and at BSU must be entered. SECTION 2 County implies the name of county at admission and at discharge. Admission and discharge BSU implies the 3 digit catchment area designation that applies from the PCIS system. Involuntary Outpatient Commitment must be the 4 digit PCIS commitment code at discharge. Date of Birth - month, day, year of birth. Use the four digits to specify year of birth. SECTION 3 At least one must be indicated. SECTION 4 Must be limited to one choice. SECTION 5 List all psychotropic and other medications, dosage and frequency. Indicate number of days supply provided to patient at dis-charge. Precautions should also be listed. Medical Care Referrals - Indicate if patient has been referred, where referred, telephone number, contact person, date and time of appointment. Any special medical conditions should be listed. Voc/Soc Rehab/Educational Referrals - Indicate if patient has been referred, where referred, telephone number, contact person, date and time of appointment. SECTION 6 List Base Service Unit at discharge. List name of Liaison. List telephone number including area code. Indicate date the BSU was notified of discharge Indicate date of aftercare appointment. Indicate time of aftercare appointment. If no appointment was made, explain. Indicate if there was a meeting with patient prior to discharge and if liaison attended. Indicate if liaison involved. SECTION 7 Indicate source of income and amount, if known. If patient is not a recipient, indicate date of referral, status of application, any action to be taken, contact person and telephone number, including area code. Indicate Medical Assistance number and plan number for any applicable medical insurance. MH 537 3/11 American LegalNet, Inc. www.FormsWorkFlow.com AFTERCARE PLAN SUMMARY AND DISCHARGE FORM002 1 002 NAME STATE FACILITY PCIS D/C CODE DISCHARGE ADDRESS TELEPHONE NUMBER DISCHARGE DATE ADMISSION DATE FACILITY CASE NO. BSU CASE NO. 2002 COMMITMENT COUNTY AT ADMISSION AT DISCHARGE ADMISSION BSU DISCHARGE BSU INVOL. OUTPATIENT COMMITMENT (Specify) DATE OF BIRTH SOCIAL SECURITY NO. DIAGNOSES AT DISCHARGE (Psych. & Med.) NAME OF RESPONSIBLE RELATIVE RELATIONSHIP RELATIVE222S ADDRESS TELEPHONE NUMBER 3002 TYPE OF DISCHARGE PLANNED UNPLANNED AMA HOSPITAL RECOMMENDED UNAUTHORIZED ABSENCE COURT DISPOSITION OTHER TRANSFER OUT DEATH 4 TYPE OF PLACEMENT INSTITUTIONAL COUNTY JAIL INTERMEDIATE CARE OTHER STATE FACILITY STATE CORRECTIONAL V.A. OTHER SKILLED NURSING COMMUNITY HOSPITAL COMMUNITY CRR PCH INDEPENDENT LIVING DOM/FOSTER CARE RELATIVE/ GUARDIAN CHILD/ADOLESCENT RESIDENTIAL TAX ROOMING HOUSE NAME OF CORRECTIONAL FACILITY CONTACT (if applicable) TELEPHONE NUMBER 5 MEDICATION AT DISCHARGE NAME DOSAGE/INSTRUCTIONS NO. DAYS SUPPLIED Rx PRECAUTIONS MEDICAL CARE REFERRALS NOT NEEDED REFUSED REFERRAL NOT MADE SPECIAL MEDICAL CONDITIONS AGENCY TELEPHONE NUMBER CONTACT PERSON DATE OF APPOINTMENT TIME A.M. P.M. VOC./SOC. REHAB./EDUCATIONAL REFERRALS NOT NEEDED REFUSED REFERRAL NOT MADE AGENCY TELEPHONE NUMBER CONTACT PERSON DATE OF APPOINTMENT TIME A.M. P.M. MH 537 3/11 American LegalNet, Inc. www.FormsWorkFlow.com 6 AFTERCARE - FOLLOWUP BSU: LIAISON NAME TELEPHONE NUMBER DATE NOTIFIED OF DISCHARGE DATE OF A/C APPT. TIME A.M. P.M. NO APPT. MADE - EXPLAIN LIAISON - INVOLVEMENT MET WITH PATIENT PRIOR TO DISCHARGE? YES NO ATTENDED PLANNING MEETING? YES NO NOT INVOLVED? YES NO 7 INCOME CAO SSI SS VA OTHER APP. DENIED RECIPIENT AMOUNT $ NON-RECIPIENT DATE REFERRED STATUS OF APP. ACTION NEEDED CONTACT PERSON TELEPHONE NUMBER HEALTH INSURANCE/M.A. POLICY NO. COMMENTS: MH ADVANCE DIRECTIVE INFORMATIONAL BROCHURE PROVIDED AT DISCHARGE SIGNED CSP (Dated ) GIVEN TO CONSUMER UPON DISCHARGE. PREPARED BY DATE COMPLETED DATE SENT TELEPHONE NUMBER (NETWORK) MH 537 3/11 American LegalNet, Inc. www.FormsWorkFlow.com