Disenrollment Form
School-Based Intervention Program
	ESM Client ID:
	
		   Provider ID:	

	First  Name:	                  Middle  Initial:	Last Name:	                                                Suffix:	
  Disenrollment Date:                /               /
                                                  MM          DD            YYYY	
  Disenrollment Reason:  Select one 	
	 Completed, no additional referrals needed	 Withdrew prior to completion	
	 Completed, referred to A-CRA	  Withdrew prior to completion, referred to A-CRA	
	 Completed, referred to Outpatient	  Withdrew prior to completion, referred to Outpatient	
	 Completed, referred to Inpatient	 Withdrew prior to completion, referred to Inpatient	
	 Completed, referred to Other	 Withdrew prior to completion, referred to Other	

Data Entry Notes:

Step 1; Search for client
Step 2: Select Client hyperlink (last name)
Step 3. Select Enrollments from left menu bar
Step 4. Click on ‘Active’ Enrollment ID hyperlink
Step 5. Edit Enrollment Status to ‘Closed’
Step 6: Select Disenrollment Reason
Step 7: Edit Enrollment End Date
Step 8. Save