Enrollment Assessment
Gambling
	Enrollment Date:                   /           /
                                           mm      dd       yyyy	
			ESM Client ID:	
			   Provider ID:	

  All questions marked with  must be completed.   Boxes marked with   = Refer to Keys on page 3
 	First  Name:		Last Name:		
	1. Unique Client Code		2.  Intake/Clinician Initials:		
	3.  Number of days between initial contact with the program by the client or 
     someone on behalf of the client and enrollment :    (unknown = 999)		
	4.  Source of Referral:	            	5..  Client Type (Check one)    Primary      Collateral       	6.. Psycho-education Client?   Yes       No     	
	7. Do you have children?	Yes       No       Refused      Unknown      If ‘Yes’, complete Q7a – Q7c.  If no, skip to Q8	
	  7a. Number of Children Under 6:		     7b. Number of Children  6-18:		7c. Children Over 18:		
	8. Employment status at Enrollment:	       	9. Days worked past month?		
	10.  Where do you usually live?  (Check one - If client is currently homeless, enter shelter or street)	
	  01 House or apartment	  03 Institution	  05 Shelter/mission	 07  Foster Care	  99 Unknown	
	  02 Room/boarding house	  04 Group home	  06 On the streets	 88  Refused	
	11. Client Lives With?  (Check all that apply)	
	  Alone	  Child under 6	  Child over 18	  Parents	  Roommate/Friend	
		  Child 6-18	  Spouse/Equiv	  Other Relative	  Unknown	
	12. Use of mobility aid? Check all that apply		
	  None                      Crutches                  Walker                  Manual wheelchair              Electric wheelchair	
	13. Vision Impairment	                 
			14. Hearing Impairment  	    	         
	
	15. SelfCare/ADL Impairment	      			16. Developmental Disability			
	 17. Prior Mental Health Treatment:   0  No History      01  Counseling     02  One Hospitalization      03   More than one hospitalization	
	18. During the past 12 months, did you take any prescription medication that
      was prescribed for you to treat a mental or emotional condition?	01  Yes      02   No    88   Refused     99  Unknown	
	19. Number of prior admissions to each substance abuse treatment modality:   		
	Detox:		Residential:		Outpatient		Opioid:		Drunk Driver:		Other:				
	20. Currently receiving services from a state agency:     (Check all that apply)		
	  None              DCF            DYS                                DOC              MPB           OCP	       DMH                DDS          	
	  DPH         DTA             DMA/MassHealth           EEC               MRC           MCB         MCDHH         Other	
	21. Number of arrests in the past 30 days?                       		(Section 35 is not an arrest, it is a civil commitment)	

	       T5. Interest in stopping nicotine/tobacco use at Disenrollment:  			
	        No	  Yes, Within 6 Months	 Yes, Within 30 days     	Does Not Apply (already stopped)	Refused    	Unknown	

	27. Types of last regular alcohol and/or drug use (check all that apply)	
	1	 None 	F	 Non Rx Methadone	L	  Other Stimulants	
	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 			
	28. Rank substances by entering corresponding letter for substances listed above in Question 27. (If no secondary or tertiary substance, leave blank)	
	     28a.  Primary Substance 	
	 28b.  Secondary Substance 		28c. Tertiary Substance			
	29.   Needle Use?  	0  Never                         		2   3 to 11 months ago     		4  Past 30 days       		
	1  12 or more months ago                		3  1 to 2 months ago		5  Last week		

	22. Gambling History: 	
		Ever   Gamble	Age: 1st Bet 	Last  Bet See Code *	Freq. of Last Bet
See Code *			Ever Gamble	Age: 1st Bet 	Last  Bet 
See Code *	Freq. of Last Bet
See Code *	
		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						L	Other						
	23. Rank gambling by entering corresponding letter for preferred type of gambling. Use letter listed above in Question 22. 
     (If no secondary or tertiary gambling choice, leave blank)	
	     23a. Primary Gambling Type  	23b.  Secondary Gambling Type  	23c.  Tertiary Gambling Type  	
	24. Has gambling caused you to have legal problems?      Yes      No     	
	25.  What is the number of times in your lifetime that your gambling has led to you being arrested? 	
	26.    T1. Tobacco Use?     Yes   No   Refused   Unknown    If answer to T1 is ‘Yes’ complete T2-T5. If ‘No’ skip to Question 27		
	        T2.   Age of first use:		T3.  Last Use:	       	T4.  Number of cigarettes smoked per day? (indicate number of 
       cigarettes, not number of packs: 1 pack = 20 cigarettes):		
	30.   Are you currently receiving Medication Assisted Treatment?
         If Yes, answer Q30a -. If No, Assessment is complete 	 Yes       No     	
	30a. Are you receiving Methadone Treatment  If Yes Assessment is complete, If No answer 30b-30c	 Yes       No     	
	30b. Are you receiving Suboxone or Vivitrol Treatment?   Select Below
       Buprenorphine (Suboxone)             Extended release injectable naltrexone (Vivitrol)		
	30c. Is your Suboxone or Vivitrol prescription for the treatment of alcohol use disorder, opioid use disorder, or both?
       Alcohol Use Disorder           Opioid Use Disorder                        Both		

Q4. Source of Referral at Enrollment	

Code	 	

Code	Code	
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	CSS – Clinical Stabilization Services	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 and Care	
08	Medication Assisted 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/MassHeath	
13	Youth Program	66	Office of Community Corrections	99	Unknown	
14	Sober House	67	Dept. of Corrections			
15	Information and Referral	68	Dept. of Probation			
17	Second Offender Aftercare	69	Massachusetts Parole Board			

Q8  Employment Status at Enrollment	
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	Q. 13 Vision Impairment		Code	Q. 14 Hearing Impairment	
0	None: Normal Vision		0	None: Normal hearing requiring no correction	
1	Slight: vision can be or is corrected with glasses/lenses		1	Slight: Hearing is or can be adequately corrected with amplification (eg hearing aid)	
2	Moderate: “Legally blind” but having some minimal vision		2	Moderate: Hard of hearing, even with amplification	
3	Severe: No usable vision		3	Severe: Profound deafness	
				
Code	 Q15. Self Care/ADL  Impairment		Code	Q16 Developmental Disability	
0	None: No problem accomplishing ADL skills such as bathing, dressing and other self care		0	None	
1	Slight: Uses adaptive device(s) and/or takes additional time to accomplish ADL but does not require attendant		1	Slight Developmental Disability	
2	Moderate: Needs personal attendant up to 20 hours a week for ADL		2	Moderate Developmental Disability	
3	Severe: Requires personal attendant for over 20 hours a week for ADL		3	Severe Developmental Disability	

Code	T2 Frequency of Last Use		Code	T2 Last Use of Tobacco		Code	T4. Interest in Stopping Tobacco use	
1	Less than once a month	5	Daily		1	12 or more months ago	7	Refused		1	No, not thinking of stopping	
2	1-3 times a month	6	None		2	3-11 months ago	8	Unknown		2	Yes, within next 6 months	
3	1-2 times a week				3	1-2 months ago				3	Yes, within next 30 days	
4	3-6 times a week				4	Past 30 days				4	Does not apply (already stopped)	
					5	Last Week				88	Refused	
					6	Today				99	Unknown	
	Q22. Gambling History Questions	
Code	Last Bet			Frequency of Last Bet 	
1	12 or more months ago	4	Past 30 days		1	Less than once a month	4	3-6 times a week	
2	3-11 months ago	5	Last week		2	1-3 times a month	5	Daily	
3	1-2 months ago	6	Today		3	1-3 times a week