PATH Discharge Summary Template

Enclosure 24

FY 2013-14 PATH Program Discharge Summary

Client Name: ______

Discharged to: ______

Address: ______

Phone: ______

Enrollment Date: ______Discharge Date: ______

Type of Discharge: Low Impact (Dropped Out, Refused Service, Lost Contact) Medium Impact (Remains Homeless but Linked to Mental Health Services) High Impact (Temporarily or Permanently Housed and Linked to Mental Health Services)

HOUSING STATUS UPON DISCHARGE 1. Homeless: Outdoors Abandoned Building Short-Term Shelter Unknown

2. Temporary Housing: Long-Term Shelter Homeless Service Center Transitional Housing (up to 24 months) Motel Residential Treatment Program Living with Family/Friends

3. Permanent Housing: Supportive Housing Program Shelter + Care Section 8 Voucher Leases Own Apartment/Room/House Other ______

4. Corrections or Institution: Jail or Correctional Facility Hospital Nursing Home

Was Client’s Housing Status Improved from Initial Contact to Discharge? YES NO

Outcome Measures OBTAINED FOLLOWING SERVICES AND RESOURCES DURING ENROLLMENT: Check Housing (temporary, transitional, permanent) Assisted Attained Mental Health Services Assisted Attained Income Benefits (SSI/SSDI) Assisted Attained Employment Assisted Attained N/A Medical Insurance or Coverage Plan Assisted Attained N/A Additional Services General Assistance Income California ID Self Help (i.e. 12 step programs) Dental Services VA Benefits Primary Health Care CalFresh Program/ Food Stamps TANF Substance Abuse Services Other ______

DISCHARGE SUMMARY Comments: ______

PATH Staff Name (Print): ______Date: ______

PATH Staff Name (Signature):______

PATH 2013-14 Request for Application Page 1 of 2 Enclosure 24

FY 2013-14 PATH Program Discharge Summary Instructions

A discharge summary is required for all PATH enrolled individuals. This information collected on the discharge summary assists in collecting information for the Quarterly Performance Report and PATH Annual Report. All of the above information is required to be collected upon discharge from the PATH Program with the exception of address and phone number.

PATH 2013-14 Request for Application Page 2 of 2