Client Name: Date of Birth

A D A P T Discharge Aftercare Plan-ORM BEHAVIORAL SERVICES

Client Name: Date of Birth: Instructions: Complete form and give a copy to the client/parent during the final session. Turn in original form with the Discharge Review. If services ended without a final session, the Adapt office will send a copy of this plan to the client/parent when it is turned in. REASON FOR DISCHARGE Decision to terminate services with Adapt due to the following reason: Goals met, no need for further treatment Parent/client requested termination Goals not met, maximum benefit reached Other: Other: Inactive due to: CURRENT MEDICATIONS TO CONTINUE ______CURRENT SERVICES TO CONTINUE Client is currently receiving the following services from other providers: No current services 1-Individual/Family Therapy 5-Residential treatment 9-Case management 2-Behavior Analysis 6-Substance Abuse therapy 10-Tutoring 3-Medication Management 7-Speech therapy 11-Mentoring 4-Support group 8-Occupational therapy 12-Other: Service# from Service# from REFERRALS FOR NEW SERVICES RECOMMENDED (include contact phone # for provider if not on list below) The following new services are recommended from other providers: No services recommended 1-Individual/Family Therapy 5-Residential treatment 9-Case management 2-Behavior Analysis 6-Substance Abuse therapy 10-Tutoring 3-Medication Management 7-Speech therapy 11-Mentoring 4-Support group 8-Occupational therapy 12-Other: Service# from Service# from If services other than those listed above are needed, you may contact your insurance to request a list of network providers in your area. If you do not have insurance, the following agencies provide services for free or have reduced fees, based on the client’s ability to pay (sliding scale fees):  Halifax Behavioral: 841 Jimmy Ann Dr, Daytona Beach, FL 32114, 386-425-3900  Stewart Marchman/ACT: 1220 Willis Avenue, Daytona Beach FL 32114, 386-236-3200 or Access Center 800-539-4228 If the agencies listed above do not work out, you may call 211 (United Way Helpline) for other options.

Resuming services with Adapt: If services from Adapt are needed and wanted in the future, they can be restarted by completing a Referral Form found on the website (www.Adapt-FL.com) and faxing it to the local Adapt office. You may also call the local office to make the referral: Volusia/Flagler/St. John’s counties: 533 N. Nova Rd. #204, Ormond Beach FL 32174, 386-898-5003

Copy of Aftercare Plan given to client/parent during final session. Copy of Aftercare Plan to be sent to client/parent after discharge. (date sent:______)

Clinician Signature: ______Date:______