Individual Shelter Inappropriate Discharge Reporting Form

This secure form is for individual adult homeless shelter providers to report situations when an individual has come directly from a hospital, nursing facility, behavioral health facility, or other institution and is not appropriate to reside in shelter. The responses will be shared with the Executive Office of Housing and Livable Communities (EOHLC) and the Executive Office of Health and Human Services (EOHHS). While all responses will be reviewed, the information will be utilized primarily for developing and refining a Commonwealth-wide discharge planning policy; individual situations will generally not receive a direct response from either the state nor the discharging facility. If you need a response about a specific situation, please contact the discharging facility directly. EOHHS/EOHLC considers inappropriate discharges to shelter to include: - Situations in which the individual cannot perform basic activities of daily living, including bathing, toileting, and eating without significant support. - Situations in which the individual poses a clear risk to themselves and/or others. - Situations in which the shelter was not contacted before the individual was sent from the facility to the shelter - Situations in which the individual was housed prior to admission and the facility did not pursue available alternatives to shelter These responses are vital so that EOHHS/EOHLC can develop data on the scale of the issue, can identify which facilities may need state intervention, and the specific needs of clients leaving facilities and ending up in shelter.

Reporting person's information

What is your name?(Required)

Discharged person's information

Discharged Person's name
Discharged Person's Date of Birth

Discharging facility's information

Where is the discharging facility located (complete as much as you know)

Information about the discharge

When did the discharge occur?(Required)