Enrollment Assessment
            Family Residential & Sober Living
                          Children
	Enrollment Date:                   /           /
                                           mm      dd       yyyy	
		ESM Client ID:	
		Provider ID:	
Questions (Q) marked with  must be completed.	
           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  If parent owns, check that child owns.                                                                                                                                                                      	
	  4.   Are you Chronically Homeless?
        (HUD Definition in Manual)	Yes    No       	5.   ZIP Code of Last Permanent Address:  
            If Newborn or child that has been in foster care since birth, use code 99999
            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                       
         If young child, check No or Refused.	
	  7b.  If you answered Yes to Q. 7a, please specify:                     Male to Female     Female to Male     Other, specify __________________________	
	  8.    Do you consider yourself to be:             Heterosexual    Gay/Lesbian     Bisexual     Other, specify ____________________      Refused
          If young child, check Refused.	

0

  9.   Number of days between initial contact with program and the first available appointment :     	
	  10.   Source of Referral:         DCF          Family          Residential Treatment Program    		

  99

  11.   Frequency of attendance at self-help programs (e.g. AA, NA) in 30 days prior to Admission:                    		
	  12.   Client Type                     Collateral  		
	13.  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    			

	14.    Do you have children? 	Yes      No     Refused     	If answer to Q14 is ‘Yes’, complete 14a-14d. If no, skip to Q15	
	
14a.  Number Children Under  6:		
14b. Number of Children  6-18:	
0

0

14c. Children Over 18:		
	
14d.  Are any of the children Native American Indian race?	 Yes       No   	
	15.   Are you the primary caregiver for any children?   If yes, see manual	1 Yes      2 No     Refused          	
	
9

16.   Employment status at Enrollment		   17.    Number of days worked in the past 30 days?       	
0

	18.   Where do you usually live? (Where has the client spent/slept most of the time over the last 12 months?)                      	
	1   House or apartment	3   Institution	5  Shelter/mission	 7   Foster Care	88   Refused	
	2   Room/boarding or sober house	4   Group home/treatment	6  On the streets	 8    N/A Infant		
	  19.   Who do you live with?	Parents