RELEASE OF RESPONSIBILITY FOR DISCHARGE or AGAINST STAFF ADVICE 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 : Staff Name : Client refused to sign this form. Client refused to sign this form.Client agrees to sign this form. Date: Time: AMPM Next DISCHARGE INSTRUCTION SHEET Admit Date : Discharge Date: Destination: HomeSober Living EnvironmentOthers Accompanied by: Phone: Type of Discharge: RoutineASATransfer to PHP or IOPAdministrativeOther General Instructions: Leisure/Activity: As tolerated Employment Vocational: RestrictionNo Restriction Dietary Instructions: RegularOther Items Returned to Client: Personal Belongings / ToiletriesElectronic devicesValuablesHome 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. Pt will make his appointsPt has made his appoints already BackNext DISCHARGE INSTRUCTION SHEET Client Signature on Destruction of Controlled Substance Log Detoxification Information: Not ApplicableCompletedLeft Prior to CompletionSuboxone MaintenanceVivitrol 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: Condition was stable at the time of discharge. Client Signature Date: Staff Signature Date: Staff Signature : Back
