Disenrollment Assessment
Acute	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, Mental Health	 Transferred to another SA Program		
      AMA	 Deceased	 Inappropriate	 Relapsed		
      Administrative/non-compliant	  Hospitalized, Medical	 Incarcerated			
	 First  Name:	                  Middle  Initial:	Last Name:	                                                Suffix:	
	
1.   Client Code:  	   2. Intake/Clinician Initials:	              	
	(Question 3 Displays only for Section 35 Enrollments)	  4.   Discharge Plan       Yes         No          	
	5. Referred to Self Help     Yes      No          		
	6. 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)                                                                   	                                                                                         	
	7.  Client Referrals at Disenrollment	(Referral #1 is required, Referral  # 2 &# 3 are optional)              See Manual for what determines a referral.	
	     7a. Referral #1	              	    7b. Referral #2	  	    7c.  Referral #3	                           	
	8. Are you currently pregnant or have you been pregnant in the past 9 months or since enrollment if in treatment less than 9 months? (Answer yes if either of these is true)	 Yes       No     	
	9  Number of arrests in the last 30 days or since Enrollment if in treatment less than 30 days.		
	10.   Were you receiving Medication Assisted Treatment BEFORE enrollment into this program?
         If Yes, go to Q10a,  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 Q11 , If No, answer 9c	 Yes       No     	
	10c. Were you receiving a prescription for Suboxone or Vivitrol?   Select Below
       Buprenorphine (Suboxone)             Extended release injectable naltrexone (Vivitrol)		
	10d. Was this 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 	 DMH:  Dept Mental Health	  DTA:   food stamps, TANF      	 MCB: Commission for the Blind	
 DCF: Dept Children and Families	 DDS:  Dept Developmental   Services	 DMA: Mass Health	 MCDHH: Comm for the Deaf & Hard of Hearing                        	
 DYS:  Dept Youth Services	  DPH:  e.g. HIV, WIC Not BSAS	 MRC: Mass Rehab	  Other	

    14.  Living arrangement at Disenrollment: “Where is the client going to live when he/she leaves your program” (Check one)	
  House or apartment	  Institution	  Shelter/mission	    Foster Care	  Unknown	
  Room/boarding or sober house	  Group home/Treatment	  On the streets	  Refused	
	15.  Was the client homeless at Intake/Enrollment (whether or not chronic)?	   Yes       No     	
                If Yes to Q15, answer 15a and 15b.   If No to Q15, skip to Q16	
	       15a.  Detailed  Living Arrangement at Disenrollment                                      	                	
	       15b.  Permanence of Living Situation at Disenrollment*	 Permanent	  Transitional	 Refused	  Unknown	
   16.  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 Q16 Is ’No’, skip to Q20	 Yes       No	
	If Yes to Q16, please rank substance abuse problems by selecting the CURRENT primary, secondary, and tertiary substance.
Rank substances by entering the corresponding letters A-U+Z on page 3.  (Nicotine/tobacco and gambling are excluded).       
    If “Yes” to Q16, Q17a-c, Q18 & Q19are required	
  	Report Frequency of Use in the last 30 days or since Enrollment if in treatment less than 30 days.	
	17a.  Primary Substance                             		17b. Frequency of Use                             	          	17c. Route of Administration                            	   	
	17.    Did the client use a Secondary Drug during the last 30 days/since Enrollment?     Yes      No       		
	18a.  Secondary Substance                             		18b. Frequency of Use                             	          	18c. Route of Administration                           	   	
	19.    Did the client use a Tertiary Drug during the last 30 days/since Enrollment?           Yes      No       		
	19a.  Tertiary Substance                             		19b. Frequency of Use                             	          	19c. Route of Administration                           	        	
	20.   Did the client use Nicotine/Tobacco since Enrollment    Yes     No     Refused     Unknown 		

	Q 6.  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 7. Referral at Disenrollment	

Code	 	

Code		Code		
00	Referral Not Needed – Assessment Indicates that Client Does Not Require Entering Formal Treatment	20	Health Care Professional, Hospital		67 Discontinued	
95	Referral Not Needed – Appropriate Mental Health Clinical Services Already in Place	21	Emergency Room	68	Office of the Commissioner of Probation	

96	Referral Not Needed – Appropriate Substance Abuse Clinical Services Already in Place	22	HIV/AIDS Program			
97	Referral Not made – Client Dropped Out	23	Needle Exchange Program	69	Massachusetts Parole Board	
98	Referral Attempted – Not Wanted by Client		24 through 25 Discontinued	70	Dept. of Youth Services	
01	Self, Family, Non-medical Professional	 26	 Mental Health Care Professional	71	Dept. of Children and Families	
02	BMC Central Intake/Room 5		27 through 29 Discontinued	72	Dept. of Mental Health	
03	ATS/Detox	30	School Personnel, School System/College	73	Dept. of Developmental Services	
04	Transitional Support Services/TSS	31	Recovery High School	74	Dept. of Public Health	
05	Clinical Stabilization Services/CSS-CMID		32-39 Discontinued	75	Dept. of Transitional Assistance	
06	Residential Treatment	40	Supervisor/employee Counselor	76	Dept. of Early Education and Care	
07	Outpatient SA Counseling		41 through 49 Discontinued	77	Mass. Rehab. Commission	
08	Medication Assisted Treatment	50	Shelter	78	Mass. Commission for the Blind	
09	Drunk Driving Program	51	Community or Religious Organization	79	Mass. Comm. For Deaf & Hard of Hearing	
10	Acupuncture		52 through 58  Discontinued	80	Other State Agency	
11	Gambling Program	59	Drug Court	81	Division of Medical Assistance/MassHealth	
	12 & 13 Discontinued		60– 63 Discontinued			
14	Sober House	64	Prerelease, Legal Aid, Police	99	Unknown	
	15 Discontinued		65-66 Discontinued			
16	Recovery Support Center					
17	Second Offender Aftercare					
18	Family Intervention Programs					
19	Other Substance Abuse Treatment					
15a. Detailed Living Arrangement at Discharge?  (HUD)                                       				77	Mass. Rehab. Commission	
1	Emergency Shelter 	10	Rental room/house/apartment	78	Mass. Commission for the Blind	
2	Transitional Housing for Homeless	11	Apartment or House that you own.	79	Mass. Comm. For Deaf & Hard of Hearing	
3	Permanent housing for formerly homeless  	12	Living With Family 	80	Other State Agency	
4	Psychiatric Hospital or Facility 	13	Living With Friends 	81	Division of Medical Assistance/MassHealth	
5	Substance abuse/detox center	14	Hotel/Motel: no emergency shelter voucher			
6	Hospital 	15	Foster care/group home 	99	Unknown	
7	Jail; Prison or Juvenile Facility  	16	Place not meant for habitation (HUD)	
8	Don't know	17	Other (HUD)	
9	 Refused			
Questions 17a – 19c	
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			
H	PCP	R	Over the Counter		Route of Administration	
I	Other Hallucinogens	S	Club Drugs 		1	Oral (swallow and/or chewing)	
J	Methamphetamine	U	Other		2	Smoking	
		V	Fentanyl		3	Inhalation	
		 Z	K2/Spice or Other Synthetic Marijuana		4	Injection	
					5	Other	
					6	Electronic Devices/Vaping