Disenrollment Assessment
SOR
Home Visiting Initiative	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	
	      First  Name:	                             Middle Initial	Last Name:	                                                     Suffix	
	
1.   Client Code:	    2.  Intake/Clinician Initials:	              	
	3. 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,NA)                                                              	                                                                                       	
	4.  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	                              	
	                                                                                     
5.   Employment status at Disenrollment:   
                                                                       If Unknown, use 99         	8.	 6.  Number of days worked in the past 30 days or since
9.	         Enrollment if in treatment less than thirty 30 days                    If Unknown use 99.	
	7.  Number of arrests in the last 30 days or since Enrollment if in treatment less than 30 days.	             
                If Unknown, use 99	
	8.   Were you receiving Medication Assisted Treatment BEFORE enrollment into this program?
         If Yes, answer Q8a –Q8d. If no, skip to Q9 	 Yes       No     	
	8a. Did you continue to receive Medication Assisted Treatment while in this program?	 Yes       No     	
	8b. Were you receiving Methadone Treatment  If Yes skip to Q10, If No answer 8c-8d	 Yes       No     	
	8c. Were you receiving a prescription for Suboxone or Vivitrol?   Select Below
       Buprenorphine (Suboxone)             Extended release injectable naltrexone (Vivitrol)		
	8d. Was your Suboxone or Vivitrol prescription for alcohol use disorder, opioid use disorder, or both?
       Alcohol Use Disorder           Opioid Use Disorder                        Both		
	Q9 – Q9c are not required if answered Yes to Q8		
	9.   Did you START Medication Assisted Treatments while in this program?  If No, skip to Q10	 Yes       No     	
	9a. Did you receive Methadone Treatment  if Yes, skip to Q10, if No go to Q9b-9c	 Yes    No     	
	9b. Did you receive a prescription for Suboxone or Vivitrol?   Select Below      
          Buprenorphine (Suboxone)           Extended release injectable naltrexone (Vivitrol)		
	9c. Is your Suboxone or Vivitrol prescription for alcohol use disorder, opioid use disorder, or both?
       Alcohol Use Disorder           Opioid Use Disorder                        Both	

  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			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		

	11.  Currently receiving services from a state agency:      Check all that apply.	
   	 None	  MPB:  Parole	 DDS:  Developmental Disabilities	 DMA: MassHealth  	 MCDHH: Deaf & Hard of 
                      Hearing	
   	 DCF: Children and Families	 OCP:  Probation	  DPH:  e.g., WIC not BSAS 	 MRC: Mass Rehab Comm.	 DEEC Early Ed & Childcare	
   	 DYS: Youth Services	 DMH:  Mental Health	  DTA:  e.g. food stamps, TANF      	 MCB: Comm for the Blind	  Other	
   12.  Living arrangement at Disenrollment:  (Check one)	
   	       House or apartment	  Institution	  Shelter/mission	   Foster Care	  Unknown	
   	       Room/boarding or sober house	  Group home/Treatment	  On the streets	  Refused	
	  H1.  Was the client homeless at Intake/Enrollment (whether or not chronic)	   Yes       No     If Yes, QH2 -QH3 are required  If No, skip to Q13	
	  H2.  Detailed living arrangement at Disenrollment                                       	                	
	  H3.  Permanence Of living situation at Disenrollment*	  Permanent	  Transitional	 Refused	  Unknown	
      13.  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 answer to Q13 is ’No’, skip to Q16     	 Yes       No     	
If Yes to Q13, please rank substance abuse problems by entering the CURRENT primary, secondary, and tertiary substance.
 Enter the corresponding letter A-U+Z. from the table on pg 4  (nicotine/tobacco and is excluded).   If Yes to Q13, Q13a-c, Q14and Q15 are required	
Report the Frequency of Use in the last 30 days or since Enrollment if in treatment less than 30 days.	
	13a. Primary Substance                             		13b. Frequency of Use                           	   	                     13c. Route of Administration                            		
	14.   Did the client use a Secondary Drug during the last 30 days/since Enrollment?     Yes      No       		
	14a. Secondary Substance                             		14b. Frequency of Use                             		14c. Route of Administration   		
	15.   Did the client use a Tertiary Drug during the last 30 days/since Enrollment?           Yes      No       		
	15a. Tertiary Substance                             		15b. Frequency of Use                             		15c. Route of Administration                           	        	
	16.  Have you had any overdoses in the past year?  Yes      No    If no, skip to Q17a	
	       16a. Were you administered Narcan after your overdose(s) in the past year?  Yes      No     	

	17a. Did the client use Nicotine/Tobacco since Enrollment                 Yes       No    Refused     Unknown    
     If you answered Yes to Q17a, answer 17b-17d. If No, skip to Q18	
	17b. Number of cigarettes currently smoked per day? (Indicate number of cigarettes, not number of packs: 1 pack = 20 cigarettes):  
         If client uses another type of nicotine/tobacco product, mark Zero (0)  		
	17c. Interest in stopping nicotine/tobacco use at Disenrollment:    		
	 1No	2Yes, Within 6 Months	 3Yes, Within 30 days     	4Does Not Apply (already stopped)	 88Refused    	99Unknown	
	17d. While in this program, did the client attempt to stop using nicotine/tobacco?          01Yes        02No    88Refused     99Unknown	
	 18.   WITS Client ID:		19.   Interview Date:                  /               /                                              	
			mm        dd             yyyy  		

	 Q 3  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 4. Referral at Disenrollment	

Code	 	

Code		Code		
00	Referral Not Needed – Assessment Indicates that Client Does Not Require Entering Formal Treatment	17	Second Offender Aftercare	64	Prerelease, Legal Aid, Police	
95	Referral Not Needed – Appropriate Mental Health Clinical Services Already in Place	18	Family Intervention Programs		65-67 Discontinued	
96	Referral Not Needed – Appropriate Substance Abuse Clinical Services Already in Place	19	Other Substance Abuse Treatment	68	Office of the Commissioner of Probation	
97	Referral Not made – Client Dropped Out	20	Health Care Professional, Hospital	69	Massachusetts Parole Board	
98	Referral Attempted – Not Wanted by Client	21	Emergency Room	70	Dept. of Youth Services	
01	Self, Family, Non-medical Professional	22	HIV/AIDS Program	71	Dept. of Children and Families	
02	BMC Central Intake/Room 5	23	Needle Exchange Program	72	Dept. of Mental Health	
03	ATS/Detox		24 through 25 Discontinued	73	Dept. of Developmental Services	
04	Transitional Support Services/TSS	26	Mental Health Care Professional	74	Dept. of Public Health	
05	Clinical Stabilization Services/CSS-CMID		27 through 29 Discontinued	75	Dept. of Transitional Assistance	
06	Residential Treatment	30	School Personnel, School System/College	76	Dept. of Early Education and Care	
07	Outpatient SA Counseling	31	Recovery High School	77	Mass. Rehab. Commission	
08	Medication Assisted Treatment		32-39 Discontinued	78	Mass. Commission for the Blind	
09	Drunk Driving Program	40	Supervisor/employee Counselor	79	Mass. Comm. For Deaf & Hard of Hearing	
10	Acupuncture		41 through 49 Discontinued	80	Other State Agency	
11	Gambling Program	50	Shelter	81	Division of Medical Assistance/MassHealth	
	12 & 13 Discontinued	51	Community or Religious Organization	82	Early Intervention	
14	Sober House		52 through 58  Discontinued	83	Family Support Programs (i.e. home visiting programs, CBHI	
	15 Discontinued	59	Drug Court			
16	Recovery Support Center		60– 63 Discontinued	99	Unknown	
 Q.5 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 			
5 	Not in Labor Force-Student 	10 	Not in Labor Force- Incarcerated 	99	Unknown	
 H2. Detailed Living Arrangement at Discharge  	
1	Emergency Shelter 	10	Rental room/house/apartment	
2	Transitional Housing for Homeless	11	Apartment or House that you own.	
3	Permanent housing for formerly homeless  	12	Living With Family 	
4	Psychiatric Hospital or Facility 	13	Living With Friends 	
5	Substance abuse/detox center	14	Hotel/Motel: no emergency shelter voucher	
6	Hospital 	15	Foster care/group home 	
7	Jail; Prison or Juvenile Facility  	16	Place not meant for habitation 	
8	Don't know	17	Other 	
9	 Refused			
				
 Questions 13a – 15c  	
 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		 Route of Administration	
H	PCP	R	Over the Counter		1	Oral (swallow and/or chewing)	
I	Other Hallucinogens	S	Club Drugs 		2	Smoking	
J	Methamphetamine	U	Other		3	Inhalation	
		V	Fentanyl		4	Injection	
		 Z	K2/Spice or Other Synthetic Marijuana		5	Other	
					6	Electronic Devices/Vaping