DELAWARE DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH CONSUMER REPORTING FORM DISCHARGE REPORT PAGE 1 OF 2 LAST NAME FIRST NAME M.I. TREATMENT MODALITY [] MH MENTAL HEALTH UNIT NAME (SELECT [] AD ALCOHOL AND DRUG ONLY ONE) [ ] DU CO-OCCURRING(MH & AD) [] GA GAMBLING TREATMENT STREET UNIT ID # — CITY STATE ZIP — COUNTY —( ) MCI # HOME TELEPHONE DSAMH ADMISSION DATE / / 0 0 0 MARITAL STATUS [] M MARRIED [] S SINGLE [] D DIVORCED [] X SEPARATED [] W WIDOWED [] U UNKNOWN 01-12 ELEMENTARY/ HIGH SCHOOL 13-16 COLLEGE/ POST SECONDARY 17 MASTERS 18 PHD/MD EDUCATION 19 POST DOCTORAL 96 NEVER COMPLETED ANY GRADE HIGHER THAN PRE-SCHOOL OR KINDERGARTEN 97 UNKNOWN WRITE IN HIGHEST GRADE COMPLETED CONSUMER'S PRIMARY SOURCE OF INCOME [] 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 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 SKILLS TRAINING PARTICIPATION [] C CURRENT INVOLVEMENT [] N NONE [] F FINISHED DURING TREATMENT [] D DROPPED OUT DURING TREATMENT [] U UNKNOWN SCHOOL PARTICIPATION [] C CURRENT INVOLVEMENT [] N NONE [] F FINISHED DURING TREATMENT [] D DROPPED OUT DURING TREATMENT [] U UNKNOWNPRIMARY 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 SECONDARY EMPLOYMENT (DURING PAST 30 DAYS) [] P PART TIME [] M MILITARY [] S STUDENT [] V VOLUNTEER [] O OTHER [] N NONE [] U UNKNOWN CONSUMER'S GROSS INCOME PER YEAR $ , NUMBER DEPENDENT ON CONSUMER'S INCOME WRITE IN NUMBER (01 -20) 97 UNKNOWN HOMELESS AT ANY TIME DURING PAST 30 DAYS? [] Y YES [] N NO [] U UNKNOWN VETERAN STATUS [] Y YES [] V VOLUNTEER [] O OTHER [] U UNKNOWN [] N NO [] U UNKNOWN CODE CODE CODE SEE DSM IV MANUAL • • • SUBSTANCE ABUSE - DESIGNATED CODES ONLY DSM IV DIAGNOSIS AXIS 1: CLINICAL DISORDERS 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 NUMBER OF ARRESTS 30 DAYS PRIOR TO DISCHARGE DOCUMENT NO. 35-06-10-11-10-05 DSAMH CONSUMER REPORTING FORM DISCHARGE REPORT PAGE 2 OF 2 DATE OF LAST SERVICE / / DISCHARGE DATE / / TREATMENT UNIT ID # MCI # — 00 0 ALERT INFORMATION -(S = SELF REPORT, C = CLINICIAN REPORT) -MARK ALL THAT APPLY, BUT ONLY ONE PER ITEM DISCHARGE REASON CURRENTLY PREGNANT S[ ]C[] TB ACTIVE INJECTION DRUG USE EVER []G PROGRAM COMPLETED S[ ]C[] TB HISTORY HERE -ALL GOALS S[ ]C[] HISTORY OF SUBSTANCE ABUSE []Y YES []Y YES []S PROGRAM COMPLETED []N NO []N NO HERE -SOME GOALS []U UNKNOWN []U UNKNOWN S[ ]C[] HISTORY OF MENTAL ILLNESS []E ELIGIBILITY LAPSED []D CONSUMER DIED S[ ]C[] PSYCHIATRIC DISABILITY []F FAILED TO MEET CRITERIA S[ ]C[] NONE []A ADMIN. DISCONTINUATION/ LOST CONTACT []C CORRECTION/JAIL ALCOHOL & DRUG USE MATRIX []R REFUSED SERVICE []T TX CONT. OTHER PROGRAM N NO USE IN PAST MONTH PRIMARY SECONDARY TERTIARY FREQUENCY OF USE []O OTHER SUBSTANCE TYPE []U UNKNOWN I INFREQUENT (1-3 TIMES PAST MONTH) FREQUENCY OF USE O OFTEN (1-2 TIMES PER WEEK) F FREQUENTLY FUNCTIONING IMPROVED (3-6 TIMES PER WEEK) []Y YES [] U UNKNOWN ROUTE OF ADMINISTRATION D DAILY []N NO M MORE THAN TWICE DAILY AGE OF FIRST USE U UNKNOWN DRUG DEPENDENCE REDUCED ROUTE OF ADMINISTRATION SUBSTANCE TYPE CODES TO USE IN BOX ABOVE []Y YES [] U UNKNOWN []N NO []X NOT APPLICABLE 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 PRIMARY DESTIN./AGENCY CODE V INTRAVENOUS ME METHAMPHETAMINE BE BENZODIAZEPINE ST STEROIDS 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 []T TRANSFERRED N NONE []R REFERRED OP OTHER OPIATES & SYNTHETICS PC PCP U UNKNOWN []A ADVISED FURTHER SERVICE U UNKNOWN []N NO MORE SERVICES ADVISED []U UNKNOWN SOCIAL SUPPORT/CONNECTEDNESS (SUPPORT GROUPS - NA, AA, ETC.) SECOND. DESTIN./AGENCY CODE []Y YES []N NO []U UNKNOWN []T TRANSFERRED []R REFERRED []A ADVISED FURTHER SERVICE []N NO MORE SERVICES ADVISED []U UNKNOWN TERTIARY DESTIN./AGENCY CODE []T TRANSFERRED []R REFERRED []A ADVISED FURTHER SERVICE []N NO MORE SERVICES ADVISED []U UNKNOWN PRIMARY THERAPIST ID PERSON COMPLETING FORM ID DATE OF COMPLETION //