Disenrollment Assessment
STR_ATR	ESM Client ID:	
		   Provider ID:	
        All Questions marked with a  must be completed                                                                                                   Boxes  marked  with   = Refer to key at end of form	
  Disenrollment Date:             	/             /		
	mm      dd       yyyy		
  Disenrollment Reason:  Select one 	
      Assessment 	 Completed 	 Hospitalized, Medical	 Incarcerated	 Relapsed	
      Against Counselor Advice - ACA	 Drop Out	 Hospitalized, Mental Health	 Moved		
      Administrative/non-compliant	  Deceased	 Inappropriate	 Transferred to another SA Program	
	      First  Name:	                             Middle Initial	Last Name:	                                                     Suffix	
	
1.   Client Code:  	    2.  Intake/Clinician Initials:	              	
	3.   Client Type           Primary  	  4.   Discharge Plan    1Yes       2No          	
	5a. Referred to Self Help    1Yes      2No          	  	
	5b. Frequency of attendance at self-help programs in the last 30 days or since Enrollment if in treatment less than 30 days. (e.g. AA,NA)                                                                    	                                                                                          	
	6.  Client referrals at Disenrollment	(referral #1 is required, referral #2 & 3 are optional)                           See Manual for what determines a referral.	
	     Referral  #1	              	     Referral  #2	  	     Referral  #3	                           	
	                                                                                     
7.   Employment status at Disenrollment: 
             If Unknown, use 99         	    	8.	 8.  Number of days worked in the past 30 days or since
9.	         Enrollment if in treatment less than thirty 30 days                   If Unknown use 99.	
	9.  Number of arrests in the last 30 days or since Enrollment if in treatment less than 30 days.	             
            If Unknown, use 99	

	10.   Were you receiving Medication Assisted Treatment BEFORE enrollment into this program?
         If Yes, answer Q10a -Q10d. If no, skip to Q11 	 Yes       No     	
	10a. Did you continue to receive Medication Assisted Treatment while in this program?	 Yes       No     	
	10b. Were you receiving Methadone Treatment  If Yes skip to Q12 , If No answer 10c-d	 Yes       No     	
	10c. Were you receiving a prescription for Suboxone or Vivitrol?   Select Below
       Buprenorphine (Suboxone)             Extended release injectable naltrexone (Vivitrol)		
	10d. Was your Suboxone or Vivitrol prescription for alcohol  use disorder, opioid use disorder, or both?
       Alcohol Use Disorder           Opioid Use Disorder                        Both		
	Q11 – Q11c are not required if answered Yes to Q10		
	11.   Did you START Medication Assisted Treatments while in this program?  If No, skip to Q12	 Yes       No     	
	11a. Did you receive Methadone Treatment  if Yes, skip to Q12, if No go to Q11b	 Yes    No     	
	11b. Did you receive a prescription for Suboxone or Vivitrol?   Select Below      
          Buprenorphine (Suboxone)           Extended release injectable naltrexone (Vivitrol)		
	11c.. Is your Suboxone or Vivitrol prescription for alcohol  use disorder, opioid use disorder, or both?
       Alcohol Use Disorder           Opioid Use Disorder                        Both	

  12.   Indicate the Social or Health Service provided to clients during treatment – While in your Program.  See Manual for definition of services                  	
                          0 = Not Provided            1= Provided by Your Agency             2 = Provided by Another Agency          3 = Provided by Both Your Agency and Another Agency	

Legal Aid Services			Medication for Emotional Problem			Literacy Services			Medication for Withdrawal		
Drug Screening			Housing			English as a 2nd  Language			TB Testing		
Treatment for Medical Problems			GED			Job Placement/Referral			TB Treatment		
Treatment for Emotional Problems			Vocational Training			Financial Counseling			STD/STI, HIV, Hep C Testing		
Nicotine Replacement Therapy			Family Planning			Prenatal Care			STD/STI, HIV, Hep C Treatment		
Medication for Medical Problems			Child Care			Post-partum Care			Parenting Classes		
	13. Currently receiving services from a state agency:      Check all that apply.	
   	 None	  MPB:  Parole	 DDS:  Dept Developmental Srvs	 DMA: MassHealth  	 MCDHH: Comm Deaf
       & Hard of Hearing	
   	 DCF: Dept Children and Families	 OCP:  Probation	  DPH:  e.g., WIC not BSAS Srvcs	 MRC: Mass Rehab Comm.	  Other	
   	 DYS:  Dept Youth Services	 DMH:  Dept Mental Health	  DTA:  e.g. food stamps, TANF      	 MCB: Comm for the Blind		
   14.  Living arrangement at Disenrollment:  (Check one)	
   	  House or apartment	  Institution	  Shelter/mission	   Foster Care	  Unknown	
   	  Room/boarding or sober house	  Group home/Treatment	  On the streets	  Refused	
	  H1.  Was the client homeless at Intake/Enrollment (whether or not chronic)	   Yes       No     If Yes, QH2 -QH3 are required  If No, skip to Q15	
	  H2.  Detailed living arrangement at Disenrollment                                       	                	
	  H3.  Permanence Of living situation at Disenrollment*	 Permanent	  Transitional	 Refused	  Unknown	
      15.  Has there been any drug or alcohol use in the last 30 days or since Enrollment if in treatment less than 30 days?
                If the client left treatment unexpectedly, base answer on last face-to-face session.   If answer to Q15 is ’No’, skip to Q18a     	 Yes       No     	
If Yes to Q15, please rank substance abuse problems by entering the CURRENT primary, secondary, and tertiary substance.
 Enter the corresponding letter A-U+Z. from the table on pg3   (nicotine/tobacco and gambling are excluded).   If Yes to Q15: Q15a-c, Q16 and Q17 are required	
Report the Frequency of Use in the last 30 days or since Enrollment if in treatment less than 30 days.	
	15a. Primary Substance                             		15b. Frequency of Use                           	   	                     15c. Route of Administration                            		
	16.   Did the client use a Secondary Drug during the last 30 days/since Enrollment?     Yes      No       		
	16a. Secondary Substance                             		16b. Frequency of Use                             		16c. Route of Administration   		
	17.   Did the client use a Tertiary Drug during the last 30 days/since Enrollment?           Yes      No       		
	17a. Tertiary Substance                             		17b. Frequency of Use                             		17c. Route of Administration                           	        	
	18a. Did the client use Nicotine/Tobacco since Enrollment                 Yes       No    Refused     Unknown    
     If you answered Yes to Q18a, answer 18b-18d. If No, go to STR Questions	
	18b. Number of cigarettes currently smoked per day? (Indicate number of cigarettes, not number of packs: 1 pack = 20 cigarettes):  
         If client uses another type of nicotine/tobacco product, mark Zero (0)  		
	18c. Interest in stopping nicotine/tobacco use at Disenrollment:    		
	 1No	2Yes, Within 6 Months	 3Yes, Within 30 days     	4Does Not Apply (already stopped)	 88Refused    	99Unknown	
	18d. While in this program, did the client attempt to stop using nicotine/tobacco?          01Yes        02No    88Refused     99Unknown	

STR-ATR Supplemental Questions
	 WITS Client ID:		   Interview Date:                  /               /
                                              mm        dd             yyyy  	
	Criminal Justice	
	1.  In the past 30 days, have you:	
	a.	Been arrested? 	Yes      No     Refused     Don’t Know		
	b.	Spent a night in jail/prison? 	Yes      No     Refused     Don’t Know  		
	c.	Committed a crime? 	Yes      No     Refused     Don’t Know		
	2. Are you currently:		
	a.	Awaiting charges, trial, or sentencing?	Yes      No     Refused     Don’t Know		
	b.	On parole or probation?	Yes      No     Refused     Don’t Know		
	ER/Trauma	
	3.  During the past 30 days, did you receive emergency room treatment for: 		
	a.	 A physical complaint? 	Yes      No     Refused     Don’t Know		
	b.	Mental or emotional difficulties? 	Yes      No     Refused     Don’t Know		
	c.	Alcohol or substance abuse? 	Yes      No     Refused     Don’t Know		
	4. During your time in this STR program, have you ever experienced or witnessed a
    traumatic event? (For example, community violence, school violence, work place violence,
    domestic violence, terrorism, natural disaster, family death, or military involvement)	Yes      No     Refused    Don’t Know     Missing	
	     4a. If yes, have you experienced recurring physical and or emotional symptoms
           as a result of experiencing or witnessing a traumatic event (s)?	 Yes      No     Refused    Don’t Know     Missing       	
	Social Connectedness 	
	5.  In the past 30 days, did you have any interaction with the recovery community  (i.e., recovery 
     centers, faith-based organizations, peer-operated organizations, or  meetings with recovery coaches)?	Yes      No       Refused    Don’t Know     	
	Employment and Income	
	6.  Are you currently enrolled in school  or a  job
      training program?	 Not Enrolled   Enrolled    Enrolled Part-time     Other      Refused    Don’t Know     	
	        8a. If other, specify			
	 7.  How much money have you received from the following sources in the past 30 days?  		
	     7a. Wages	  Received money from Wages     Refused     Don’t Know       Not Applicable	
	                                                    7a1. How much money have you received from Wages     $_______________________________	
	     7b. Public Assistance	  Received money from Public Assistance     Refused     Don’t Know       Not Applicable		
	                                                      7b1. How much money have you received from Public Assistance? $__________________________	
	     7c. Disability	  Received money from Disability     Refused     Don’t Know       Not Applicable		
		  7c1. How much money have you received from  Disability?  $_______________________________	
	     7d. Other	  Received money from Other     Refused     Don’t Know       Not Applicable	
	             7d1. If “Received money from Other”,   specify source___________________________________	
	             7d2. How much money have you received from Other?   $_______________________________	
	Housing	
	8.  In the past 30 days, where have you been living most of the time? 	
		Shelter (safe havens, transitional living center, low-demand facilities, reception centers, other temporary day or evening facility, Wyman House,     hotel, Friends of the Homeless, Salvation Army)	
		Street/outdoors (sidewalk, doorway, park, public or abandoned building)	
		Institutional (hospital, nursing home, jail/prison)	
		Housed    (If housed, select appropriate subcategory)	
		Refused	
		Don’t know	
	          8a.  If Housed, Select Appropriate Subcategory?	
		Own/rent apartment, room, or house (includes sober homes)	
		Someone else’s apartment, room, or house	
		Dormitory/college residence	
		Halfway house (includes recovery homes, Opportunity House, My Sister’s House, Phoenix House, Gandara House for men or women)	
		Residential treatment (includes Hope Center)	
		Other housed,  specify ____________________________________________________	
	Quality of Life: 	
	9. Do you have enough energy for everyday life?
              Not at all  A little   Moderately  Mostly  Completely  Refused    Don’t Know     	
	10. Do you have enough money to meet your needs?
              Not at all  A little   Moderately  Mostly  Completely  Refused    Don’t Know     	
	11. How would you rate your quality of life?
              Very poor   Poor      Neither poor nor good   Good   Very good  Refused    Don’t Know     	

	Recovery Goal Planning	
	 Select the answer that best matches your current status in the following recovery domains:	
	12.  Connection to the recovery community	  Very poor    Poor      Neither    Good    Very good	
	13.  Physical health	 Very poor    Poor      Neither    Good    Very good	
	14.  Mental health, emotional health, and/or relationships with others 	 Very poor    Poor      Neither    Good    Very good	
	15.  Spiritual health	 Very poor    Poor      Neither    Good    Very good	
	16.  Living arrangements	 Very poor    Poor      Neither    Good    Very good	
	17. Education or employment situation	 Very poor    Poor      Neither    Good    Very good	
	18. Personal daily living (e.g., finances, safety, daily routines)	 Very poor    Poor      Neither    Good    Very good	
	19. Family functioning/parenting	 Very poor    Poor      Neither    Good    Very good	

	20. Please identify and prioritize up to 3 recovery goal areas for your time in this component of STR.       Select only one for each Recovery Goal	
		20a.
Recovery goal area 1*	20b.
Recovery goal area 2	20c..
Recovery goal area 3	
	- Connection to recovery community				
	- Physical health				
	- Mental health, emotional health, and/or relationships with others				
	- Spiritual health				
	- Living arrangements				
	- Education or employment situation				
	- Personal daily living (e.g., finances, safety, daily routines)				
	- Family functioning/parenting				
	 -Other				
	-  Not Applicable				
	20a1 If selected Other for Recovery Goal 1, please describe	                 	
	20b1 If selected Other for Recovery Goal 2, please describe		
	20c1 If selected Other for Recovery Goal 3, please describe		
				
	21.  Have you had any overdoses in the past year?	Yes      No     Yes      No     		
	       21a.  If yes, were you administered Narcan?	Yes      No     		

	 Q 5b  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 wk	
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 6. Referral at Disenrollment	

Code	 	

Code		Code		
00	Referral Not Needed – Assessment Indicates that Client Does Not Require Entering Formal Treatment	17	Second Offender Aftercare	64	Prerelease, Legal Aid, Police	
95	Referral Not Needed – Appropriate Mental Health Clinical Services Already in Place	18	Family Intervention Programs		65-67 Discontinued	
96	Referral Not Needed – Appropriate Substance Abuse Clinical Services Already in Place	19	Other Substance Abuse Treatment	68	Office of the Commissioner of Probation	
97	Referral Not made – Client Dropped Out	20	Health Care Professional, Hospital	69	Massachusetts Parole Board	
98	Referral Attempted – Not Wanted by Client	21	Emergency Room	70	Dept. of Youth Services	
01	Self, Family, Non-medical Professional	22	HIV/AIDS Program	71	Dept. of Children and Families	
02	BMC Central Intake/Room 5	23	Needle Exchange Program	72	Dept. of Mental Health	
03	ATS/Detox		24 through 25 Discontinued	73	Dept. of Developmental Services	
04	Transitional Support Services/TSS	26	Mental Health Care Professional	74	Dept. of Public Health	
05	Clinical Stabilization Services/CSS-CMID		27 through 29 Discontinued	75	Dept. of Transitional Assistance	
06	Residential Treatment	30	School Personnel, School System/College	76	Dept. of Early Education and Care	
07	Outpatient SA Counseling	31	Recovery High School	77	Mass. Rehab. Commission	
08	Medication Assisted Treatment		32-39 Discontinued	78	Mass. Commission for the Blind	
09	Drunk Driving Program	40	Supervisor/employee Counselor	79	Mass. Comm. For Deaf & Hard of Hearing	
10	Acupuncture		41 through 49 Discontinued	80	Other State Agency	
11	Gambling Program	50	Shelter	81	Division of Medical Assistance/MassHealth	
	12 & 13 Discontinued	51	Community or Religious Organization			
14	Sober House		52 through 58  Discontinued	99	Unknown	
	15 Discontinued	59	Drug Court			
16	New Recovery Support Center		60– 63 Discontinued			
 Q.7 Employment Status at Disenrollment	
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 			
5 	Not in Labor Force-Student 	10 	Not in Labor Force- Incarcerated 	99	Unknown	
 H2. Detailed Living Arrangement at Discharge  	
1	Emergency Shelter 	10	Rental room/house/apartment	
2	Transitional Housing for Homeless	11	Apartment or House that you own.	
3	Permanent housing for formerly homeless  	12	Living With Family 	
4	Psychiatric Hospital or Facility 	13	Living With Friends 	
5	Substance abuse/detox center	14	Hotel/Motel: no emergency shelter voucher	
6	Hospital 	15	Foster care/group home 	
7	Jail; Prison or Juvenile Facility  	16	Place not meant for habitation 	
8	Don't know	17	Other 	
9	 Refused			
 Questions 15a – 17c  	
 Primary/Secondary/Tertiary Substance Codes		 Frequency of Use	
A	Alcohol	K	Other Amphetamines		1	No use during last 30 days or since enrollment	
B	Cocaine	L	Other Stimulants		2	1-3 times during last 30 days or since enrollment	
C	Crack	M	Benzodiazepines		3	1-2 times per week during last 30 days or since enrollment	
D	Marijuana / Hashish	N	Other Tranquilizers		4	3-6 times per week during last 30 days or since enrollment	
E	Heroin	O	Barbiturates		5	Daily use during the last 30 days or since enrollment	
F	Prescribed Opiates	P	Other Sedatives / Hypnotics		99	Unknown	
G	Non-prescribed Opiates	Q	Inhalants		 Route of Administration	
H	PCP	R	Over the Counter		1	Oral (swallow and/or chewing)	
I	Other Hallucinogens	S	Club Drugs 		2	Smoking	
J	Methamphetamine	U	Other		3	Inhalation	
		 Z	K2/Spice or Other Synthetic Marijuana		4	Injection	
					5	Other	
					6	Electronic Devices/Vaping