Shelter & Detox Form

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Shelter & Detox Form
First Name (or initial): ________________
Last Name (or initial): ________________
Gender: Male | Female | Transgender-Male | Transgender-Female
DOB: _________
SSN (all or last 4): __________________
Consent Decree Member: Yes | No
Ethnicity: Not Hispanic | Puerto Rican | Mexican | Cuban | Other Specific Hispanic | Specific Origin Not Specified
Race: 01-White | 02-Black/African Amer. | 03-Amer. Indian/Alaskan Native | 04-Asian | 05-Native Hawaiian/PI | Other
Veteran Status: Yes | No
Intake Facility: ______________________________
Intake Staff: ________________________________
County: _______________________________
*Referral: ___________________________________
Initial Contact Date: _________________
Intake Date: _______________________
Pregnant (if female): Yes | No
If Yes, Due Date: ___________ If Yes, Prenatal Care: Yes | No___
HIV Positive: Yes | No | Unknown
Hepatitis C Positive: Yes | No | Unknown
Injection Drug Use: Never | In Last 6 Mos. | In Last 5 Years | Prior to last 5 years
If IDU, Did Client share needles in past year _________
Problem Area: 01-Substance Abuse
02-Affected Other
03-Evaluation Only
Admission Type: Shelter & Detox
Admission Date: ________________
Affected/Co-dependent: Yes | No
# Prior SA Tx. Admissions: __________
MH/MR Diagnosis: 00-None | 01-Diagnosed Mental Illness | 02 Mental Retardation | 97-Unknown
Education Level: ______________
*Employment Status: ________________
*Primary Income Source: _____________________
*Insurance Type: ___________________________
*Living Arrangements: ____________________________
*Marital Status: ____________________________________
st
Substance (Primary): _____________ Frequency: ____________ Method: ___________ Age 1
Used: _____
st
Substance (Secondary): _____________ Frequency: ____________ Method: ___________ Age 1
Used: _____
st
Substance (Tertiary): _____________ Frequency: ____________ Method: ___________ Age 1
Used: _____
*Medication Assisted Treatment: __________________
st
Does Client currently use Tobacco? __________ If yes, age of 1
use: ________ Method: ____________
If Yes, Frequency: ½ pack/can a day | 1 pack/can a day | 1 ½ pack/can a day | 2 pack/can a day | More
*Legal Status: ________________________
Arrests past 12 months: _____
Arrests past 30 days: ______
# OUI Arrests past 12 months _______
Program Enrollment: _________________
*Answer values not listed on the front page
2/8/2016

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