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Run: Case Closure and Discharge Summary Form

Case Closure and Discharge Summary Form for documenting services delivered, goal progress, closure reason, and the post-discharge plan before a case is forma...

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Client and Case Identification

Client ID / Case Number (required)

Enter the unique client or case identifier from your case management system. Do not enter Social Security Numbers or other sensitive identifiers here.

Client First Name (required)

Client Last Name (required)

Program / Service Line (required)

Select the program under which this case was managed.

If 'Other', specify program name

Date Case Was Opened (required)

Date of Case Closure (required)

Case Manager Name (required)

Supervising Manager / Reviewer (required)

Name of the supervisor who will approve this closure.

Reason for Closure

Primary Reason for Case Closure (required)

Additional Detail on Closure Reason

Provide any context that clarifies the closure reason, especially for 'Lost to Follow-Up', 'Administrative', or 'Other' selections.

Number of Contact Attempts Before Closure (if applicable)

Required for 'Lost to Follow-Up' closures. Document attempts per your agency's policy.

Services Delivered

Services Provided During This Case (required)

Select all service types delivered to this client.

If 'Other' service selected, describe

Total Number of Service Contacts / Sessions (required)

Total documented contacts (in-person, phone, virtual) over the life of the case.

Narrative Summary of Services Delivered (required)

Provide a concise narrative of the key services delivered and the client's engagement over the course of the case.

Goal Attainment

Goal Attainment Summary (required)

List each goal from the service plan and rate its attainment at closure. Add a row for each goal.

Overall Goal Attainment Rating (required)

Select the rating that best reflects the client's overall progress across all goals.

Primary Barriers to Goal Achievement (if applicable)

Select all barriers that significantly impacted goal attainment.

Post-Discharge Plan and Referrals

Client's Status at Discharge (required)

Referrals Made at Discharge

List each referral made, including the organization name, service type, and date of referral. Leave blank if no referrals were made.

Client Provided Informed Consent for Referrals

Confirm whether the client consented to information sharing with referred providers, per your agency's consent and data-sharing policy.

Were there any unresolved safety concerns at the time of closure? (required)

If yes, document the steps taken and any mandatory reporting obligations fulfilled.

Safety Concern Details and Actions Taken

Describe the safety concern, actions taken, and any mandatory reporting completed. Do not include information that would re-identify third parties unnecessarily.

Post-Discharge Plan Narrative (required)

Summarize the plan for the client after closure, including any self-sufficiency steps, ongoing supports, or follow-up scheduled.

Case Manager Attestation and Supervisor Review

Case Record Completeness (required)

Confirm that the case record is complete before submitting for closure.

Yes No N/A

Accuracy Attestation (required)

Yes No N/A

Case Manager Signature (required)

Electronic signature of the case manager submitting this closure.

Date of Submission (required)

Supervisor Review Notes (completed by reviewer)

Supervisor may add notes, corrections, or conditions for approval here prior to signing off.

Supervisor Closure Decision

To be completed by the approving supervisor.

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