Admission/Discharge Reporting Clinic Directors and Program Coordinators - please indicate admissions/discharge information for your site/program. This information will be used for the organization's admissions data and communicate status to the general admissions team (admissions director, vice president, CEO and billing/operations). Department*Youth ServicesAdult ServicesPerson Served Name*Please do not use HIPAA codes. First Last Admisions Action*Please indicate if this admission-related event is an admit (adding a new service at Balance Autism), a voluntary discharge (individual's choice), or an involuntary discharge (provider's choice).AdmitVoluntary DischargeInvoluntary DischargeEffective Date of Admit/Discharge*Please indicate admit or discharge date (should match authorization dates). Date Format: MM slash DD slash YYYY Service Type*CAPConsultationIndividual RespiteGroup RespiteHABSCL HourlySCL DailySupported EmploymentCampusYouth HomeService Location*AltoonaBurlingtonCliveCedar FallsCedar RapidsIowa CityQuad CitiesIs this individual currently receiving other services at Balance Autism?YesNoWill this individual continue to use other services at Balance Autism?*YesNoLocation of individual (i.e. ANK1, Site 15, House 2, etc)*Do you need Operations to prepare a financial agrement for this indvidual's new service?YesNoReason for DischargePlease elaborate on the reasons the individual is discharging from these services.Additional Information(Optional) Please add anything additional that may be helpful to the admissions or billing/operations teams.Submitted by* First Last EmailTo receive a copy of this summary, please enter your email address.