This discharge form is to be completed by the pediatrician and given to the family to guide them in following up on referrals and having the correct information to provide to the receiving/referred professional. It may also be useful to the pediatrician when communicating directly with a mental health professional. This form is not intended to provide a complete history nor is it for the referred professional to complete. The form can be completed electronically, printed, and provided to the family at the end of the visit. You may also save the form to your files.