Horizon House Sober Living
Discharge Report
Member Information
Client ID (Enter to auto-populate)
Member Name
Date of Discharge
House
321
351
Staff Completing Report
Reason for Discharge
Relapse
Behavioral violation
Non‑compliance with house rules
Honorary discharge
End of benefits
Other (explain)
Relapse Details
Alcohol/Drugs/Paraphernalia Found
Member Admitted to Using
Member Appeared to Be Under the Influence
Positive Test Results
Random
For Cause
Type of Test
Urine
Breathalyzer
Oral swab
Other
Substances Detected
Date/Time Test Administered
Incident Details
Details of Cause for discharge / Staff observations
Member Response / Statement
Safety & Exit Procedures
Member removed all property
Property stored
Yes
No
If yes, Property Storage Log will open upon completion of this form
Property disposed of - provide details:
Member left without incident:
Yes
No
Transitioning to:
Transportation:
Self
Other
Member Status:
(2) Alumni
(3) No access
(6) Relapse, eligible for return after review
See below notes
Room Inspected:
Room cleaned and ready to occupy
Maintenance or repairs needed
(Maintenance Request Form will open after completion)
Property left
Stored
(Property Storage Form will open after completion of this form)
Disposed of
Brief description of property and how disposed of:
Additional Notes:
Signatures
Staff Signature
Clear
Date
Member Signature (if cooperative)
Clear
Date
Member departed prior to completion of this form
Actual date and time of departure:
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