DELAWARE DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH CONSUMER REPORTING FORM ADMISSION REPORT TREATMENT PAGE 1 OF 2 UNIT NAME TREATMENT LAST NAME UNIT ID # — FIRST NAME M.I. MODALITY (SELECT ONLY ONE) []MH []AD []DU []GA MENTAL HEALTH ALCOHOL / DRUG CO-OCCURRING (MH & AD) GAMBLING STREET BIRTHDATE CITY STATE MCI # — S.S.# ZIP COUNTY DSAMH ADMISSION DATE LEAVE BLANK UNTIL ADMISSION / / // 00 0 — — —HOME TELEPHONE GENDER [] M MALE [] F FEMALE HISPANIC/LATINO [] P PUERTO RICAN [] M MEXICAN [] C CUBAN [] O OTHER HISPANIC [] N NOT OF HISPANIC ORIGIN [] U UNKNOWN RESIDENTIAL ARRANGEMENT [] PU PRIVATE RESIDENCE - UNSUPERVISED [] PS PRIVATE RESIDENCE - SUPERVISED [] FC ADULT FOSTER CARE [] BH BOARDING HOUSE [] GU GROUP SETTING/ UNSUPERVISED [] GS GROUP SETTING/ SUPERVISED [] NH NURSING HOME/ ICF/SNF [] CJ CORRECTIONS FACILITY/JAIL [] I OTHER INSTITUTION [] O OTHER [] N NONE/HOMELESS [] U UNKNOWN ( ) MARITAL STATUS [] M MARRIED [] S SINGLE [] D DIVORCED [] X SEPARATED [] W WIDOWED [] U UNKNOWN PRIMARY LANGUAGE [] E ENGLISH [] S SPANISH [] M SIGN (MANUAL) [] O OTHER [] U UNKNOWN VETERAN STATUS [] Y YES [] N NO [] U UNKNOWN PRI. HEALTH INSURANCE [] M MEDICARE [] A MEDICAID [] E MEDICAID MCO [] C CHAMPUS [] B BLUE CROSS/ BLUE SHIELD [] V VA [] H HMO [] G OTHER GOVERNMENT FUNDS FOR CARE [] P OTHER PRIVATE COMMERCIAL [] O OTHER [] N NONE [] U UNKNOWN CURRENT LEGAL INVOLVEMENT [] CP CHARGES PENDING [] SP CONVICTED -SENTENCE PENDING [] UP SENTENCED -UNSUPERVISED PROBATION (SENTAC I) [] FS SENTENCED -FIELD SUPERVISION (SENTAC II) [] IS SENTENCED -INTENSE SUPERVISION (SENTAC III) [] QI SENTENCED -QUASI-INCARCERATION (SENTAC IV) [] CJ SENTENCED -PRISON/CORRECTIONS/JAIL (SENTAC V) [] HX HISTORY OF LEGAL INVOLVEMENT BUT NOT CURRENT [] N NO CURRENT INVOLVEMENT OR HISTORY [] U UNKNOWN MEDICARE DOCUMENT NO.: 35-06-10-11-10-05 [] AA AMERICAN INDIAN / ALASKAN NATIVE [] AP AA PLUS OTHER RACE/S [] BL BLACK / AFRICAN AMERICAN [] BP BL PLUS OTHER RACE/S [] CA WHITE/CAUCASIAN [] CP CA PLUS OTHER RACE/S [] HA NATIVE HAWAIIAN / OTHER PACIFIC ISLANDER [] HP HA PLUS OTHER RACE/S [] MU MULTIRACIAL, UNSPECIFIED [] PA ASIAN [] PP PA PLUS OTHER RACE/S [ ] U UNKNOWN [ ] Z NOT COLLECTED RACIAL IDENTIFICATION CHECK ONE SKILLS TRAINING PARTICIPATION [] C CURRENT INVOLVEMENT [] N NONE [] U UNKNOWN SCHOOL PARTICIPATION [] C CURRENT INVOLVEMENT [] N NONE [] U UNKNOWN PRIMARY EMPLOYMENT (DURING PAST 30 DAYS) [] F FULL TIME [] P PART TIME [] M MILITARY ARMED FORCES [] L UNEMPLOYED -LOOKING FOR WORK [] N UNEMPLOYED -NOT LOOKING [] D DISABLED/UNABLE TO WORK [] H HOMEMAKER [] S STUDENT [] R RETIRED [] I INMATE/RESIDENT OF INSTITUTION [] V VOLUNTEER [] O OTHER [] U UNKNOWN SECONDARY EMPLOYMENT (DURING PAST 30 DAYS) [] P PART TIME [] M MILITARY [] S STUDENT [] V VOLUNTEER [] O OTHER [] N NONE [] U UNKNOWN 01-12 ELEMENTARY/ HIGH SCHOOL 13-16 COLLEGE/ POST SECONDARY 17 MASTERS 18 PHD/MD 19 POST DOCTORAL 96 NEVER COMPLETED ANY GRADE HIGHER THAN PRE-SCHOOL OR KINDERGARTEN 97 UNKNOWN EDUCATION WRITE IN HIGHEST GRADE COMPLETED [] SS SOCIAL SECURITY [] SI SSI [] SD SSDI [] VD VA -DISABILITY [] VR VA -RETIREMENT [] UI UNEMPLOYMENT INSURANCE [] IL ILLEGAL [] E EMPLOYMENT [] S SPOUSE [] F FAMILY/FRIENDS [] A TANF [] G GENERAL ASSISTANCE [] P PENSION/RETIREMENT (IRA, KEOGH, SEP) [] W WORKERS' COMPENSATION [] D PRIVATE DISABILITY INSURANCE [] I INVESTMENTS/SAVINGS [] O OTHER [] N NONE [] U UNKNOWN CONSUMER'S PRIMARY SOURCE OF INCOME HOMELESS AT ANY TIME DURING THE PAST 30 DAYS? [] Y YES [] N NO [] U UNKNOWN NUMBER OF ARRESTS 30 DAYS PRIOR TO ADMISSION CONSUMER'S GROSS INCOME PER YEAR $ , CODE CODE CODE • • • NUMBER DEPENDENT ON CONSUMER'S INCOME WRITE IN NUMBER (01 -20) 97 UNKNOWN SUBSTANCE ABUSE - DESIGNATED CODES ONLY DSM IV DIAGNOSIS AXIS 1: CLINICAL DISORDERS SEE DSM IV MANUAL ALERT INFORMATION -(S = SELF REPORT, C = CLINICIAN REPORT) - MARK ALL THAT APPLY, BUT ONLY ONE PER ITEM S[ ] C [ ] TB ACTIVE S[ ] C [ ] TB HISTORY S[ ] C [ ] HISTORY OF SUBSTANCE ABUSE S[ ] C [ ] HISTORY OF MENTAL ILLNESS S[ ] C [ ] PSYCHIACTRIC DISABILITY S[ ] C [ ] NONE CURRENTLY PREGNANT [] Y YES [] N NO [] U UNKNOWN INJECTION DRUG USE EVER [] Y YES [] N NO [] U UNKNOWN DSAMH CONSUMER REPORTING FORM -ADMISSION REPORT PAGE 2 OF 2 TREATMENT UNIT ID # MCI # DATE OF FIRST CONTACT / / 00 0— FREQUENCY OF USE ALCOHOL & DRUG USE MATRIX PRIMARY SECONDARY TERTIARY N NO USE IN PAST MONTH SUBSTANCE TYPE I INFREQUENT (1-3 TIMES PAST MONTH) FREQUENCY OF USE O OFTEN (1-2 TIMES PER WEEK) F FREQUENTLY (3-6 TIMES PER WEEK) ROUTE OF ADMINISTRATION D DAILY M MORE THAN TWICE DAILY AGE OF FIRST USE U UNKNOWN ROUTE OF ADMINISTRATION SUBSTANCE TYPE CODES TO USE IN BOX ABOVE M BY MOUTH (SWALLOW) AL ALCOHOL MD NON-PRESCRIPTION METHADONE LS LSD S SMOKE CO COCAINE BA BARBITURATES HA OTHER HALLUCINOGENS B BREATHE/INHALE/SNORT CR CRACK SE OTHER SEDATIVES OR HYPNOTICS IN INHALANTS ME METHAMPHETAMINE BE BENZODIAZEPINE ST STEROIDS V INTRAVENOUS AM OTHER AMPHETAMINES TR MAJOR TRANQUILIZERS OC OVER-THE-COUNTER DRUGS I OTHER INJECTION OS OTHER STIMULANTS CS COUGH SYRUPS AND MIXTURES O OTHER O OTHER HE HEROIN MA MARIJUANA/HASHISH N NONE N NONE OP OTHER OPIATES & SYNTHETICS PC PCP U UNKNOWN U UNKNOWN ADMISSION TYPE PRESENTING PROBLEM (LEAVE BLANK UNTIL ADMITTED) SOURCE/AGENCY CODE (SEE INSTRUCTIONS FOR CODES) [] V VOLUNTARY PRIMARY []C CIVIL ORDER []J JUDICIAL (COURT ORDER) [] T TRANSFERRED LEAVE BLANK [] R REFERRED UNTIL [] U UNKNOWN SECONDARY [] S SELF-REFERRED ADMITTED [] N NONE [] U UNKNOWN [] [] Y N PREVIOUS TX FOR MH YES [] U UNKNOWN NO SOCIAL SUPPORT/CONNECTEDNESS (SUPPORT GROUPS- NA, AA, ETC.) [] Y YES [] N NO TERTIARY [] U UNKNOWN EXPECTED SOURCE OF PAYMENT PREVIOUS TX FOR ALC. & DRUGS [] Y YES [] U UNKNOWN [] N NO [] D [] I DSAMH INDIVIDUAL/FAMILY [] B BLUE CROSS/ SHIELD [] H HMO [] P OTHER PRIVATE INSURANCE [] M MEDICARE (TITLE XVIII) [] A MEDICAID (TITLE XIX) [] E MEDICAID MCO [] V VETERANS ADMINISTRATION [] C CHAMPUS [] W WORKERS' COMPENSATION [] G OTHER GOV'T FUNDS [] S SENTAC [] O OTHER [] N NONE/PROVIDER ABSORBS [] U UNKNOWN PRIMARY THERAPIST ID PERSON COMPLETING FORM ID DATE OF COMPLETION //