Q Discharge Plan Client’s Name: ________________________________________ Diagnosis Upon Admission: _________________________________________________________________________________________ Presenting Problem: _____________________________________________________________________________________________ ASAM Level Upon Admission:_____________________ Primary Counselor: ____________________________________________________ Diagnosis Upon Discharge/Indicate changes: ________________________________ ASAM Level Upon Discharge:_____________________ Reason for Discharge: _______________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Clinical Summary (Include stages of change throughout treatment and strengths and supports): Relapse Prevention Strategies: When I think, feel, behave in the following ways: Relapse Prevention Strategy Treatment Referral and Recommendations: Recovery Referral and Recommendations: Family Referral and Resources: Community Referral and Resources: FOR COUNSELOR USE ONLY: