RELEASE OF RESPONSIBILITY FOR DISCHARGE

This is to certify that I, , a client at Bella Nirvana Center I am leaving the community against staff advice. I have been aware of the risk and possible outcomes from my discharge. In addition, I presently am not experiencing suicidal and/or homicidal thoughts.
I knowingly and voluntarily assume the risk of leaving the facility against staff advice and hereby release Bella Nirvana Center from all responsibility for any injury, harm and ill effects that may result from such discharge.
Client Name:
Client Signature:
Staff Name:
Staff Signature:
Client refused to sign this form.
Staff Signature:
Date:
Time:

DISCHARGE INSTRUCTION SHEET

Admit Date:
Discharge Date:
Accompanied by:
Phone:
Destination:
Home
Sober Living Environment
Type of Discharge:
Routine
ASA
Transfer to PHP or IOP
Administrative
Other

General Instructions

Leisure/Activity:
As tolerated
Employment Vocational:
Restriction
No Restriction
Dietary Instructions:
Regular
Special
Items Returned to Client:
Personal Belongings/ Toiletries
Electronic devices
Electronic devices
Valuables
Home Meds/Prescribed by there Primary Care Provider

Medication Information:

See Medication Reconciliation Sheeto
After Discharge Follow Up Appointments:
Patient acknowledges that he/she will need to follow up with a primary care physician, psychiatrist after discharge.
Provider Appt Date Time Reason Telephone Address

DISCHARGE INSTRUCTION SHEET

Client Signature on Destruction of Controlled Substance Log
Detoxification Information:
Not Applicable
Completed
Left Prior to Completion
Suboxone Maintenance
Vivitrol Shot Maintenance
Client/ Staff Initials Using Drugs or Alcohol after you have completed a detoxification program carries the risk of overdose which could lead to death. Your body is no longer used to these substances. Even using a smaller amount than you used prior to detox could still result in an overdose. The best preventative measure is to work on your recovery plan.
If you have any questions or concerns regarding my treatment recommendations or medications I will contact Bella Nirvana Center 916.222.2181
Safety Suicide Hotlines in the event that you do not feel safe, get assistance by using one or more of the following; Call 911 or go to the Nearest ER Call your Therapist or Sponsor Call 1 800 Suicide (784-2433) National Suicide Hotline Available 24 hours each day Call 1 800 662 HELP National Drug & Alcohol Treatment Hotline Call 916.454.1100 VA Suicide HOT LINE 24/7 at 1 800 382 8387
This plan has been reviewed with me and I have been given an opportunity to ask questions
Vital Signs on Discharge:
BP
P
T
R
Client Signature:
Date:
Staff Signature:
Date:

MEDICATION RECONCILIATION

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DOSAGE:
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RX:
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