Enrollment Assessment
SOR-ATR
	Enrollment Date:                   /           /
                                           mm      dd       yyyy	
			ESM Client ID:	
			  Provider ID:	
  Questions (Q) marked with  must be completed.                                                                                             Boxes marked with   = Refer to Key at end of form 	
              First  Name:                                                                      Middle Initial:            Last Name:                                                                                   Suffix:	
	 1.    Client Code:  		 2.   Intake/Clinician Initials:	              	
	 3.    Do you own or rent a house, apartment, or room?      Yes      No       If the answer to Q3 is Yes, skip to Q5                                                                                                                                                                        	
	 4.    Are you Chronically Homeless?
       (HUD Definition in Manual)	Yes    No       	 5.  ZIP Code of Last Permanent Address: 
            Do Not enter zip code of Program.  	
	 6.   Where did you stay last night?      	
	1 Emergency shelter	  7 Jail, prison or juvenile detention facility	13 Foster care home or foster care group hm	
	2 Transitional housing for homeless persons	  8 Room, apartment, or house that you own  or rent 	14 Place not meant for habitation	
	3 Permanent housing for formerly homeless     	  9  Staying or living with a family member	15 Other	
	4 Psychiatric hospital or other psych. facility 	10 Staying or living with a friend	88 Refused	
	5 Substance abuse treatment facility or detox 	11 Room, apartment, or house to which you 
          cannot return  (future return can be uncertain)		
	6 Hospital (non-psychiatric)	12 Hotel or motel paid  for without emergency shelter voucher  	
	 7a. Do you consider yourself to be transgender?                       Yes    No    Refused       	
	 7b.  If you answered Yes to Q7a, please specify:             Male to Female     Female to Male     Other, specify __________________________	
	 8.   Do you consider yourself to be:             Heterosexual      Gay/Lesbian     Bisexual     Other, specify ___________________      Refused	
	                                                               
   9.   Source of Referral:		
	                                                                                                                                                                                                 
  10.   Frequency of attendance at self-help programs (e.g. AA, NA) in 30 days prior to Enrollment:                      		
	11.  Additional Client Type: Answer Yes or No to a-i	
	a.  Student                                        	Yes    No    	f.  Probation    	Yes    No    	
	b.  Pregnant                                      	Yes    No    	g. Parole   	Yes    No    	
	c.  Postpartum                                  	Yes    No    	h. Federal Probation                                       	Yes    No    	
	d.  Veteran/ Any Military Service      	Yes    No    	i.  Federal Parole	Yes    No    	
	e. Prison	Yes    No    			

	12.   Employment status at Enrollment:	                  			
	13. Number of days worked in the past 30 days?				
	14.   Where do you usually live? (Where has the client spent/slept most of the time over the last 12 months?)	
	1   House or apartment	4   Group home/treatment	7   Foster Care	
	2   Room/boarding or sober house	5  Shelter/mission 	88   Refused	
	3   Institution	6  On the streets		
	15. Prior Mental Health Treatment 	0  No history        	1  Counseling	2  One  hospitalization	3  More than one  hospitalization	
	16. During the past 12 months, did you take any prescription medication that
      was prescribed for you to treat a mental or emotional condition?	1  Yes         2  No     88  Refused      99  Unknown 	
	17.  Number of prior admissions to each substance abuse treatment modality (0 - 5 admissions, ‘5’ = 5 or more, 99=unknown)  Do not count this tx
                                                                                                                                                                                                                              .     episode)	
	         
               Detox	         
               Opioid	         
                  Other	         

              Residential	         
               Drunk Driver	         		
	              Outpatient	
               Section 35			
	18.   Are you currently receiving Medication Assisted Treatment?
         If Yes, answer Q18a . If No, skip to Q19	 Yes       No     	
	18a. Are you receiving Methadone Treatment  (If Yes skip to Q19)	 Yes       No     	
	18b. Are you receiving Suboxone or Vivitrol Treatment?   Select Below
       Buprenorphine (Suboxone)             Extended release injectable naltrexone (Vivitrol)		
	18c. Is your Suboxone or Vivitrol prescription for alcohol use disorder, opioid use disorder, or both?
       Alcohol Use Disorder           Opioid Use Disorder                        Both		
	19.  Currently receiving services from a state agency: (Check all that apply)	
	  None	  DMH Mental Health	  DTA e.g. food stamps	  MCDHH Deaf & Hard of Hearing	
	  DCF Children and Families	  DDS Development Disabilities	  MRC Mass Rehab Commission	  Other 	
	  DYS Youth Services	  DPH e.g. HIV/STD; not BSAS .	  MCB Commission for Blind		
	20. Number of arrests in the past 30 days?                       		(Section 35 is not an arrest, it is a civil commitment)	

	21. History Substance Mis-use, Nicotine/Tobacco Use & Gambling
For pharmaceutical drugs prescribed for the client, only code misuse (more than the recommended dosage) or non-medical use. (Example - If the client was prescribed a benzodiazepine for a mental health disorder and used per instruction, do not list on History Table.)  Note:  For the safety of the client all drugs used must be recorded in the client record.(See Manual for commercial names.)	Have You Ever Mis-Used/Bet	Age of First Use/Bet	Last Use/Bet	Freq of Last Use/Bet	Route of Admin Code	
		Y	N					
  A	Alcohol                                                                                               For Alcohol, enter first age of intoxication							
  B	Cocaine							
  C	Crack							
  D	Marijuana / Hashish							
  E	Heroin							
  F	Prescribed Opiates     Misuse/non-medical use of pharmaceutical opiates which were prescribed for the client.        							
  G	Non-prescribed Opiates  Non-medical use of pharmaceutical opiates which were not prescribed for the client							
  H	PCP							
   I	Other Hallucinogens							
  J	Methamphetamine							
  K	Other Amphetamines							
  L	Other Stimulants							
  M	Benzodiazepines							
  N	Other Tranquillizers							
  O	Barbiturates							
  P	Other Sedatives / Hypnotics							
  Q	Inhalants							
  R	Over the Counter							
  S	Club Drugs                                                       							
  U	Other							
  V	Fentanyl							
  X	Nicotine/Tobacco                                                              Includes cigarettes, cigars, chewing tobacco, inhalers							
 Z	K2/Spice or Other Synthetic Marijuana							
	22.  Rank substances by entering corresponding letter for substances listed above in Question 21. (If no secondary or tertiary substance, leave blank)
(Nicotine/Tobacco CANNOT be marked as a primary/secondary/or tertiary drug)	
	       Primary Substance                             		                  Secondary Substance                                		Tertiary Substance		
	23.   Needle Use?  	0  Never                         		2   3 to 11 months ago     		4  Past 30 days       		
	1  12 or more months ago                		3  1 to 2 months ago		5  Last week		
	24 Have you had any overdoses in your lifetime?  Yes       No     (If No, skip to Q25)	
	    24a. How many overdoses have you had in your lifetime? (1-99)		24b. How many overdoses have you had in past year? (0-99)		
	    24c. Were you administered Narcan after your overdose(s) in the past year?  Yes      No     Skip Q24c if Q24b = 0		
	 25.   WITS Client ID:		26.   Interview Date:                  /               /                                              		
			mm        dd             yyyy  		

 Q9. Source of Referral at Enrollment	

Code	 	

Code	Code	
01	Self, Family, Non-medical Professional	20	Health Care Professional, Hospital	67	Department of Corrections	
02	BMC Central Intake/Room 5	21	Emergency Room	68	Office of the Commissioner of Probation	
03	ATS/Detox	22	HIV/AIDS Programs	69	Massachusetts Parole Board	
04	Transitional Support Services/TSS	23	Needle Exchange Programs	70	Dept. of Youth Services	
05	Clinical Stabilization Services/CSS-CMID		24 through 25 Discontinued	71	Dept. of Children and Families	
06	Residential Treatment	26	Mental Health Care Professional	72	Dept. of Mental Health	
07	Outpatient SA Counseling	30	School Personnel, School System/Colleges	73	Dept. of Developmental Services	
08	Medication Assisted Treatment	31	Recovery High School		74 through 76 Discontinued	
09	Drunk Driving Program		32 through 39 Discontinued	77	Mass. Rehab. Commission	
10	Acupuncture	40	Supervisor/Employee Counselor	78	Mass. Commission for the Blind	
11	Gambling Program		41 through 49 Discontinued	79	Mass. Comm. For Deaf & Hard of Hearing	
	Note: Sec 35 Options are grouped although numbers are not in sequence. Select correct #	50	Shelter	80	Other State Agency	
12	Sec 35 (WATC & MATC)	51	Community or Religious Organization		81 Discontinued	
24	Sec 35 Bridgewater MASAC		52 through 58 Discontinued	99	Unknown	
25	Sec 35 Framingham MCI	59	Drug Court			
	13 Discontinued	60	Court - Section 35			
14	Sober House	63	Court - Other			
15	Information and Referral	64	Prerelease, Legal Aid, Police			
17	Second Offender Aftercare	65	County House of Corrections/Jail			
16	Recovery Support Centers	66	Office of Community Corrections			
18	Family Intervention Program					
19	Other Substance Abuse Treatment					

	 Q 10 Frequency of Attendance at Self-Help Programs	
Code		Code		
01	No attendance in the past month	05	16-30 times in past month (4 or more times per week)	
02	1-3 times in past month (less than once per week)	06	Some attendance, but frequency unknown	
03	4-7 times in past month (about once per week)	99	Unknown	
04	8-15 times in past month (2 or 3 times per week)			

 Q 12   Employment Status at Enrollment	
Code		Code		Code		
1	Working Full Time	6	Not in Labor Force - Retired	11	Volunteer 	
2	Working Part time	7	Not in Labor Force - Disabled	12	Other	
3	Unemployed - looking	8	Not in labor force -  Homemaker	13	Maternity/Family Leave	
4	Unemployed – Not Looking	9	Not in labor force - Other	99	Unknown	
5	Not in labor force – Student	10	Not in labor force - Incarcerated			

 Q 21: SUBSTANCE MIS-USE / NICOTINE/TOBACCO / GAMBLING HISTORY

Code	Last Use Substances		Code	Frequency of Last Use/bet		Code	Route of Administration	
1	12 or more months ago		1	Less than once a month		1	Oral (swallow and/or chewing)	
2	3-11 months ago		2	1-3 times a month		2	Smoking	
3	1-2 months ago		3	1-2 times a week		3	Inhalation	
4	Past 30 days		4	3-6 times a week		4	Injection	
5	Used in last week		5	Daily		5	Other	
			99	Unknown		6	Electronic Devices/Vaping