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Discharge Form · Pro

Outpatient Mental Health Discharge & Aftercare Form

Capture discharge details, clinical summaries, aftercare plans, and medication info for outpatient mental health clients with this ready-to-use form template.

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Espresso theme

formbuilder.ai/f/outpatient-mental-health-treatment-discharge-aftercare-authorization-form

Outpatient Mental Health Treatment Discharge & Aftercare Authorization Form

Client Full Name

· · ·

Date of Birth

· · ·

Client Phone Number

· · ·

Submit

The Outpatient Mental Health Treatment Discharge & Aftercare Authorization Form is a comprehensive digital template designed for behavioral health clinics, therapists, counselors, and mental health treatment centers. It guides clinicians through capturing all essential discharge information—including client demographics, admission and discharge dates, reason for discharge, and primary diagnoses with ICD-10 codes—ensuring nothing is overlooked during the transition out of care.

The form's clinical summary section enables providers to document treatment modalities, frequency, duration, the client's condition at discharge, and progress toward treatment goals. The aftercare and continuing care plan section captures critical recommendations such as ongoing therapy, medication management, and support group referrals, along with a full medication list including dosage, frequency, and prescribing provider details.

By digitizing this process, mental health organizations reduce paperwork errors, improve care continuity, and maintain compliance with documentation standards. Whether used in private practice or a large outpatient clinic, this template helps ensure every client leaves with a clear, well-documented plan for their continued recovery.

4 Pages

30 Questions

~10min To complete

Free No credit card needed

Field types Long Text ×9 Date ×7 Full Name ×2 Short Text ×2 Dropdown ×2 Signature ×2 Phone Email Address Multiple Choice Single Choice termsandconditions

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Client Information & Discharge Details 10 questions

Client Information

1 Client Full Name * Full Name

2 Date of Birth * Date

3 Client Phone Number * Phone

4 Client Email Address Email

5 Client Home Address * Address

Discharge Details

6 Case / Medical Record Number * Short Text

7 Date of Admission to Treatment * Date

8 Date of Discharge * Date

9 Reason for Discharge * Dropdown

10 If 'Other,' please specify or provide additional context Long Text

Page 2 Clinical Summary & Aftercare Plan 8 questions

Clinical Summary at Discharge

1 Primary Diagnosis / Diagnoses at Discharge (include ICD-10 codes if applicable) * Long Text

2 Summary of Treatment Provided (modalities, frequency, duration) * Long Text

3 Client's Condition at Discharge * Dropdown

4 Progress Toward Treatment Goals * Long Text

Aftercare & Continuing Care Plan

5 Aftercare Recommendations (e.g., continued therapy, medication management, support groups) * Long Text

6 Medications at Discharge (name, dosage, frequency, prescribing provider) Long Text

7 Referrals Made (provider names, specialties, contact information) Long Text

8 Follow-Up Appointment Date Date

Page 3 Authorization & Release of Information 5 questions

Authorization for Release of Discharge Information

By completing this section, the client authorizes the release of discharge and aftercare information to the parties listed below for the purpose of continuity of care. This authorization complies with HIPAA regulations and applicable state privacy laws.

1 Authorized Recipient(s) — Name, relationship/role, and contact information * Long Text

2 Information Authorized for Release * Multiple Choice

3 If 'Specific records,' please describe Long Text

4 Authorization Expiration Date * Date

5 Right to Revoke * Single Choice

Page 4 Acknowledgment & Signatures 7 questions

Client Acknowledgment

I acknowledge that I have been informed of my aftercare plan, understand the discharge recommendations, and have had the opportunity to ask questions. I authorize the release of my information as indicated above.

1 I have read and agree to the terms of this Discharge & Aftercare Authorization Form, including the release of information as specified. * termsandconditions

2 Client Signature (or Legal Guardian Signature) * Signature

3 Date Signed by Client * Date

Clinician Confirmation

4 Discharging Clinician Name * Full Name

5 Clinician Title / Credentials * Short Text

6 Clinician Signature * Signature

7 Date Signed by Clinician * Date

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.