Service Refusal Documentation (Draft)

Simple documentation when aftercare services are declined

This is a draft form for review and evaluation purposes only.

Service Refusal Documentation

Simple documentation when aftercare services are declined

Draft

Child Name *

Case Number *

Service Package *

Select the service package to understand what aftercare services are being declined.

Date of Refusal

Who Refused Services? *

Reason for Refusal *

Conversation Notes *

Document that services remain available and plan for continued outreach as appropriate.

Informed that aftercare services remain availableWill continue monthly check-ins to offer services

Optional: Send formal letter

Generate a letter documenting the refusal and ongoing availability of services

Additional Notes