Disenrollment Assessment
Family Residential & Sober Living
Children
	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	
   Parent Completed	 Parent Administrative/non-compliant	  Parent Left Against Counselor’s Advice	 Parent Inappropriate (Level of Care)	
   Parent Dropped Out	 Parent Incarcerated	 Parent Hospitalized, Medical	 Parent Deceased	
   Parent Relapsed	 Family Transferred to another SA Program	 Parent Hospitalized, Mental Health	 DCF or Guardian Removed Child	
	      First  Name:	                               Middle Initial:	        Last Name:	                                                     Suffix:         	
	
1.   Client Code:  	  2.   Intake/Clinician Initials:	              	
	3.   Client Type                 Collateral   	 4.   Discharge Plan      1 Yes        2 No          	
	5a. Referred to Self Help    2 No          	
	5b. Frequency of attendance at self-help programs in the last 30 days or since admission if in treatment less than 30 days. (e.g. A, NA)                                                                    	
99

	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: 
	    
9

	8.	
0

  8.  Number of days worked in the past 30 days or since                                     
9.	          enrollment if in treatment less than thirty 30 days                	
    9.  Number of arrests in the last 30 days or since admission if in treatment less than 30 days.                                                                   If Unknown use 99

	
	
 Q 6. Referral at Disenrollment	

Code	 	

Code		Code		
00	Referral Not Needed – Assessment indicates that client does not require to enter formal treatment. 	18	Family Intervention Programs		65 through 67Discontinued	
95	Referral Not Needed – Appropriate Mental Health Services Already in Place.	19	Other Substance Abuse Treatment	68	Office of the Commissioner of Probation	
96	Referral Not Needed – Appropriate Substance Abuse Services Already in Place.	20	Change Health Care Professional, Hospital	69	Massachusetts Parole Board	
97	Referral Not made – Client Dropped Out	21	Emergency Room	70	Dept. of Youth Services	
98	Referral Attempted – Not Wanted by Client	22	HIV/AIDS Program	71	Dept. of Children and Families	
01	Self, Family, Non-medical Professional	23	Needle Exchange Program	72	Dept. of Mental Health	
02	BMC Central Intake/Room 5		24 through 25 Discontinued	73	Dept. of Developmental Services	
03	ATS/Detox	26	New Mental Health Care Professional	74	Dept. of Public Health	
04	Transitional Support Services/TSS		26 through 29 Discontinued	75	Dept. of Transitional Assistance	
05	Clinical Stabilization Services/CSS-CMID	30	School Personnel, School System/College		76 Discontinued	
06	Residential Treatment	31	New Recovery High School	77	Mass Rehabilitation Commission	
07	Outpatient SA Counseling		32 through 39 Discontinued	78 	Mass Commission for the Blind	
08	Medication Assisted Treatment	40	Supervisor/employee Counselor	79	Mass Commission for the Deaf and Hard of Hearing	
09	Drunk Driving Program		41 through 49 Discontinued	80	Other State Agency	
10	Acupuncture	50	Shelter	81	Division of Medical Assistance/Mass Health	
11	Gambling Program	51	Community or Religious Organization			
	12 & 13 Discontinued		52 through 58 Discontinued	99	Unknown	
14	Sober House	59	Drug Court			
	15 Discontinued		60 through 63 Discontinued			
16	New Recovery Support Centers	64	Prerelease, Legal Aid, Police			
17	Second Offender Aftercare