Remove Client from On Hold — Back to Basics Behavioral Health Services

Client Name

First Name

Last Name

Client Preferred Name

First Name

Last Name

Date to remove from on hold

YYYY

Is there a current caregiver this affects?

Yes

Current caregiver it affects and action plan

please list the caregiver(s) legal name and what action item(s) scheduling needs to accomplish

Name of person who filled out this form

First Name

Last Name