Discharge Form

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Instructions

Fields marked with an asterisk are required. The certification is not valid until a certification number is issued.

Patient Information

Patient's First Name

Patient's Last Name

ID Card Number

Phone Area Code () First Three Digits - Last Four Digits

Facility's Name

Diagnosis

Please use the most up to date ICD codes. ICD codes can be three, six or seven characters.

Primary Diagnosis

Current Height

Current Weight

Weight Loss/Gain in lbs

Weight Loss/Gain in Last Months

Comments Regarding Medical Issues Related to Eating Disorders Max characters: 200

Primary Diagnosis 2 Remove

Primary Diagnosis 3 Remove

Additional Diagnosis Add

Additional Diagnosis 2 Remove

Additional Diagnosis 3 Remove

Hidden

Hidden Remove

Hidden

Hidden Remove

Hidden

Axis V Initial GAF

Axis V Current GAF

Information Provided By:

Date of Admission

Date of Discharge

Actual Length of Stay:

Discharge Living Arrangements:

If yes, please provide date:

Follow-up Information

If no, what is the reason:

Psychiatrist Information:

Psychiatrist First Name:

Psychiatrist Last Name:

Psychiatrist Phone: Area Code () First Three Digits - Last Four Digits

Psychiatrist Date:

Therapist's Information:

Therapist First Name:

Therapist Last Name:

Therapist Phone: Area Code () First Three Digits - Last Four Digits

Therapist Date:

AA/NA:

No Information Available:

PHP:

PHP Facility Name:

PHP Phone: Area Code () First Three Digits - Last Four Digits

PHP Date:

IOP:

IOP Facility Name:

IOP Phone: Area Code () First Three Digits - Last Four Digits

IOP Date:

Medications Max characters: 255

Miscellaneous Information Max characters: 200

Last date of full diagnostic assessment