Shelter & Detox Form Page 2

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Referral
Detailed Drug Codes
Employment Status
01 - Self
Alcohol - 0100 Alcohol
Full Time (35 hrs or more)
Marijuana
02 - Family Member
Part Time (17-34 hrs)
0200 Marijuana
03 - Employer
Irregular (< 17 hrs)
0250 Synthetic Cannabis (K2/Spice)
04 - Substance Abuse Professional – (Private Practice)
Unemployed (Has sought work)
Cocaine/Crack
05 - Substance Abuse Agency
Unemployed (Hasn’t sought work)
0301 Cocaine
06 - Physician (Non-Substance Abuse Specialist)
Not in Labor Force
0302 Crack
07 - Other Professional (Non-Substance Abuse Specialist)
Full Time Volunteer
Heroin/Morphine - 0400 Heroin/Morphine
08 - DEEP (Driver Education/Evaluation Program)
Part Time Volunteer
Methadone/Buprenorphine
09 - Adult Protective Services, DHHS
0500 Methadone
Irregular Volunteer
0550 Buprenorphine/Suboxone/Subutex
10 - Child Protective Services, DHHS
Other Opiates and Synthetics
11 - Substitute Care Services, DHHS
Insurance Type:
0601 Codeine
12 - Probation/Parole, State of Maine
Private Insurance
0602 D-Propoxyphene
13 - Correctional Facility, State of Maine
Blue Cross/Blue Shield
0603 Oxycodone (Percodan)
14 - County Jails
Medicare
0604 Oxycontin
15 - Augusta/Bangor Mental Health Institute
0605 Meperidine HCL
Mainecare MEDICAID)
16 - Mental Health Agency
0606 Hydromorphone
HMO
17 - Friend
0607 Other Narcotic Analgesics
Other
0608 Pentazocine
18 - EAP
None
PCP - 0700 PCP or PCP Combination
19 - SAP
Other Hallucinogens
Living Arrangement:
20 - State/Federal Court
0801 LSD
Independent, Living Alone
21 - Formal Adjudication Process
0802 Other Hallucinogens
Independent, Living W Others
22 - Self-Help Group
Methamphetamine/Speed 0900 Methamphetamine/Speed
Dependent Living
23 - Hospital
Other Amphetamines
Homeless
24 - School
1001 Amphetamine
25 - AIDS Outreach Worker
1002 Methylphenidate (Ritalin)
1003 Methylenedioxymethamphetamine
26 - Community Probation, DSAT
Marital Status:
(MDMA, Ecstasy)
27 - Drug Court, DSAT
Never Married
Other Stimulants
28 - Network/JASAE
Married/Partnered
1100 Other Stimulants
29 - Juvenile Drug Court
Separated
1809 Bath Salts
30 - Physician/PMP
Divorced
Benzodiazepines
31 - Hospital/PMP
Widowed
1201 Alprazolam (Xanax)
99 – Other
1202 Chlordiazepoxide (Librium)
1203 Clorazpate (Tranzene)
Primary Income Source
MAT:
1204 Diazepam (Valium)
NO
01 - None
1205 Flurazepam (Dalmaine)
METHADONE
02 – Wages/Salary
1206 Lorazepam (Ativan)
BUPRENORPHINE/SUBOXONE/
03 – Alimony
1207 Triazolam (Halcoin)
SUBUTEX
04 – Food Stamps
1208 Other Benzodiazepine
CAMPRAL
Other Tranquilizers
05 – TANF
1301 Meprobarnate (Miltown)
NALTREXONE
06 – SSI
1302 Other Tranquilizers
VIVITROL
07 - Disability, Other
Barbiturates
ANTABUSE
08 – Town Welfare
1401 Phenobarbital
Legal Status:
09 – Child Support
1402 Secobarbital/Amobarbital (Tuinal)
No Legal Involvement
10 – Unemployment
1403 Secobarbital (Seconal)
Probation/Parole
11 – Social Security
Other Sedatives and Hypnotics
12 – Dealing Drugs
Furloughed
1501 Ethchlorvynol (Placidyl)
1502 Glutethimide (Doriden)
Awaiting Court
13 – Workers Compensation
1503 Methaqualone
Serving Sentence/Jail Prison
99 – Other/Investments
1504 Other Non-Barbiturate Sedatives
Formal Adjudication
1505 Other Sedatives
Driver’s License revocation (Not DEEP involved)
1506 Flunitrazepam (Rohypnol)
Other
1507 GHB/GBL
Expected Payment Source
1508 Ketamine (Special K)
01 - SAMHS (OSA)
1509 Clonazepam (Klonopin, Rivotril)
Inhalants
02 - Human Services (other than Child, Adult protective)
1601 Aerosols
03 - Corrections
1602 Nitrites
04 - Human Services (Adult or Child Protective)
1603 Other Inhalants
05 - Self Pay
1604 Solvents
06 - MaineCare (Medicaid)
1605 Anesthetics
07 - Medicare
Over the Counter
08 - Blue Cross/Blue Shield
1700 Over the counter, General
09 - HMO
1701 Diphenhydramine (Benadryl)
Other
10 - Other Private Health Insurance
1801 Diphenylhydantoin Sodium
11 - Town Assistance
(Phenytoin, Dilantin)
12 - Workers’ Compensation
1802 Other Drugs
13 - Veterans’ Administration
99 - Other
2/8/2016

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