Disenrollment Assessment
Gambling	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	
	1. First  Name:		Last Name:			
	2. Intake/Clinician Initials:					
	3.  Client Type    check one      Primary      Collateral   	
	4. Disenrollment Plan      01 Yes       02 No          	5. Referred to Self Help    01 Yes       02 No          	
	6. Frequency of attendance at self-help programs (e.g., AA, NA, etc.) in 30 days prior to discharge:	               	
	7. Client referrals at  disenrollment				
	     Referral #1	         	Referral #2	         	Referral # 3	         	
	8. Employment status at disenrollment	       	8. Days worked past month?		
	9. Number of days worked in past month                      	
    10.  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			Vocational Training				
Treatment for Emotional Problems			Literacy Services				
Housing			Job Placement/Referral				
GED			Financial Counseling				
	11. 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		
  12.  Living arrangement at Disenrollment: 	
	  House or apartment            Room/boarding house	     Institution                     Group home      	
	  Shelter/mission                   On the streets	     Foster Care                 Refused                        Unknown	

	13. Gambling SINCE Enrollment (Don’t repeat history taken at enrollment)	
		Betting Status	Last  Bet
See Code	Freq. of Last Bet			Betting Status	Last  Bet
See Code	Freq. of Last Bet	
		Y	N					Y	N			
A	Lottery -Scratch Tickets					G	Lottery/Numbers Games					
B	Casino Games					H	Sports Betting					
C	Dog/Horse Tracks, Jai Alai					I	Internet Gambling					
D	Lottery - Keno					J	Slot Machines					
E	Card Games					K	Bingo					
F	Stock Market					G	Other					
	  14. Rank gambling by entering corresponding letter for preferred type of gambling. Use letter listed above in Q13. If no secondary or tertiary choice, leave blank	
	     Primary Gambling Type                            		Secondary Gambling Type                               		Tertiary Gambling Type		
	15. Have you used alcohol and/or drugs in the past 30 days or since enrollment   If yes, answer Q16, If no skip to Q17	01 Yes       02 No          	
	A	 Alcohol	G.	 Other Opiates/Synthetics	M	 Benzodiazepines	
	B	 Cocaine	H	 PCP	R	 Over-the=Counter  	
	C	 Crack	I.	 Other Hallucinogens 	U	 Other 	
	D	 Marijuana/Hashish  	J.	   Methamphetamine	Z	 K2/Spice or Other Synthetic Marijuana	
	E	 Heroin 	K	  Other Amphetamine 			
	F	 Non Rx Methadone	L	  Other Stimulants			
	16. T1. Tobacco Use in the past 30 days or Since Enrollment?     Yes         No      Refused    Unknown  If answer to T1 is ‘Yes’, complete T2-T4  	
	 T2.   Last Use:	     	T3.  Number of cigarettes smoked per day? (indicate number of cigarettes, not number of packs: 1 pack = 20 cigarettes):		
	 T4. Interest in stopping nicotine/tobacco use at Disenrollment:  				
	 1No	2Yes, Within 6 Months	 3Yes, Within 30 days     	4Does Not Apply (already stopped)	88Refused    	99Unknown	
	 17.   Were you receiving Medication Assisted Treatment BEFORE enrollment into this program?
         If Yes, answer Q17a - Q17d. If no, skip to Q18	 Yes       No     	
	17a. Did you continue to receive Medication Assisted Treatment while in this program?	 Yes       No     	
	17b. Were you receiving Methadone Treatment  (If Yes skip to Q19 , If No answer Q18)	 Yes       No     	
	17c. Were you receiving a prescription for Suboxone or Vivitrol?   Select Below
      Buprenorphine (Suboxone)             Extended release injectable naltrexone (Vivitrol)		
	17d. Was this Suboxone or Vivitrol prescription for alcohol use disorder, opioid use disorder, or both?
      Alcohol Use Disorder                 Opioid Use Disorder                        Both		
	Q18 – Q18c are not required if answered Yes to Q17		
	18.   Did you START Medication Assisted Treatments while in this program? If No, Assessment is complete	 Yes       No     	
	18a. Did you receive Methadone Treatment (if Yes, Assessment is complete, if No go to Q18b)	 Yes    No     	
	18b. Did you receive a prescription for Suboxone or Vivitrol?   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	

Disenrollment Reasons	
Assessment Only	Hospitalized, medical	
Completed 	Hospitalized, mental health	
Drop-out	Inappropriate	
Relapsed	Moved	
Administrative/non-compliance	Enrolled in Error	
Incarcerated	Deceased	
Transferred to other substance abuse prgrm		

	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 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)	97	Unknown	
04	8-15 times in past month (2 or 3 times per week)			

Q7. Referral at Disenrollment	

Code	 	

Code	Code	
00	Referral Not Needed 	14	Sober House	67	Dept. of Correction	
97	Referral Not made – Client Dropped Out	15	Information and Referral	68	Dept. of Probation	
98	Referral Attempted – Not Wanted by Client	17	Second Offender Aftercare	69	Massachusetts Parole Board	
01	Self, Family, Non-medical Professional	19	Other Substance Abuse Treatment	70	Dept. of Youth Services	
02	BMC Central Intake – Room 5	20	Health Care Professional, Hospital	71	Dept. of Children and Families	
03	ATS - Level A	30	School Personnel, School System	72	Dept. of Mental Health	
04	Transitional Support Services	40	Supervisor/employee Counselor	73	Dept. of Developmental Services	
05	Clinical Stabilization Services - CSS	50	Shelter	74	Dept. of Public Health	
06	Residential Treatment	51	Community or Religious Organization	75	Dept. of Transitional Assistance	
07	Outpatient SA Counseling	60	Court - Section 35	76	Dept. of Early Education	
08	Opioid Treatment	61	Court - DUI	77	Mass. Rehab. Commission	
09	Drunk Driving Program	62	Court - Drugs	78	Mass. Commission for the Blind	
10	Acupuncture	63	Court - Other	79	Mass. Comm. For Deaf & Hard of Hearing	
11	Gambling Program	64	Prerelease, Legal Aid, Police	80	Other State Agency	
12	Sec 35 (WATC and MATC)	65	County House of Correction/Jail	81	Division of Medical Assistance/MassHealth	
13	Youth Program	66	Office of Community Corrections	99	Unknown	

	Q 8   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	99	Unknown	
5	Not in labor force – Student	10	Not in labor force - Incarcerated			

Code	Q13 Last Bet		Code	Q 13 - Frequency of Last Bet		Code	T2  Last Use Tobacco    		
1	12 or more months ago		1	Less than once a month		1	12 or more months ago		
2	3-11 months ago		2	1-3 times a month		2	3-11 months ago		
3	1-2 months ago		3	1-3 times a week		3	1-2 months ago		
4	Past 30 days		4	3-6 times a week		4	Past 30 days		
5	Made a bet in last week		5	Daily		5	Used in last week		
6	Today		99	Unknown		6	Today		
						88	Refused		
						99	Unknown