Enrollment Assessment
     First Offender Drunk Driving
	Enrollment Date:                   /           /
                                           mm      dd       yyyy	
			ESM Client ID:	
			   Provider ID:	
  Questions (Q) marked with  must be completed.                                                                                             Boxes marked with   = Refer to Key at end of form 	
              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                                                                                                                                                                        	
	 4.    Are you Chronically Homeless?
       (HUD Definition in Manual)	Yes    No       	5.  ZIP Code of Last Permanent Address: 
          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       	
	 7b.  If you answered Yes to Q7a, please specify:             Male to Female     Female to Male     Other, specify __________________________	
	 8.   Do you consider yourself to be:             Heterosexual      Gay/Lesbian     Bisexual     Other, specify ___________________      Refused	
	9.	Number of days between initial contact with program by client or someone on behalf of client and the first available appointment
          or bed availability:  (unknown = 999)     See Manual to help determine wait time.	
	10.	Source of Referral: :     61 Court -DUI    57 Registry of Motor Vehicles   58 Out of State DUI Referral    09 Drunk Driving Prog (transfer) 	
	                                                                                                                                                                                              
  11.   Frequency of attendance at self-help programs (e.g. AA, NA) in 30 days prior to Enrollment:                      		
	  12.   Client Type                  Primary      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:		14c. Children Over 18:		
	14d. Are any of the children of the Native American Indian race?	 1Yes       2No   	

	15.   Are you the primary caregiver for any children?   If yes, see manual.  If the client is the primary  caregiver 
       of children you must assess what arrangements have been made for their care in your full clinical assessment.	 Yes       No     Refused     	
	16.   Employment status at Enrollment:	          	17. Number of days worked in the past 30 days?		
	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	
	2   Room/boarding or sober house	4   Group home/treatment	6  On the streets	88   Refused	
	19.   Who do you live with?  (Check all that apply)                    COLLATERAL CLIENTS STOP AFTER THIS QUESTION	
	    Alone	    Child 6-18	  Spouse/Equivalent	   Other Relative	
	    Child under 6	    Child over 18	  Parents	   Roommate/Friend	
	20.  Use of mobility aid: (Check all that apply)	 None	 Crutches	 Walker	  Manual Wheelchair	 Electric Wheelchair	
	21. Vision Impairment	                 
			22. Hearing Impairment  	          	         
	
	23. SelfCare/ADL Impairment	      			24.Developmental Disability			
	25. Prior Mental Health Treatment 	0  No history        	1  Counseling	2  One  hospitalization	3  More than one  hospitalization	
	26. During the past 12 months, did you take any prescription medication that
      was prescribed for you to treat a mental or emotional condition?	1  Yes         2  No     88  Refused      99  Unknown 	
	27.  Number of prior admissions to each substance abuse treatment modality (0 - 5 admissions, ‘5’ = 5 or more, 99=unknown)  Do not count this tx. episode.	
	         
              Detox	         
              Outpatient	         
              Drunk Driver	         
              Other	
	         
              Residential	         
              Opioid	         
              Section 35		

	28.   Are you currently receiving Medication Assisted Treatment?
         If Yes, answer Q28a -28c. If No, skip to Q29 	 Yes       No     	
	28a. Are you receiving Methadone Treatment  If Yes skip to Q29	 Yes       No     	
	28b. Are you receiving Suboxone or Vivitrol Treatment?   Select Below
       Buprenorphine (Suboxone)             Extended release injectable naltrexone (Vivitrol)		
	28c. Is your Suboxone or Vivitrol prescription for alcohol use disorder, opioid use disorder, or both?
       Alcohol Use Disorder           Opioid Use Disorder                        Both		
	29.  Currently receiving services from a state agency: (Check all that apply)	
	  None	  DMH does client have a case mgr.?	  DTA e.g. food stamps	  MCDHH MA Commission  for  Deaf	
	  DCF was DSS	  DDS was DMR	  MRC Mass Rehab Commission	  Other 	
	  DYS youth services	  DPH e.g. HIV/STD; not BSAS tx..	  MCB Commission for Blind		
	30. Number of arrests in the past 30 days?                       		(Section 35 is not an arrest, it is a civil commitment)	

	31. History Substance Mis-use, Nicotine/Tobacco Use & Gambling
For pharmaceutical drugs prescribed for the client, only code misuse (more than the recommended dosage) or non-medical use. (Example - If the client was prescribed a benzodiazepine for a mental health disorder and used per instruction, do not list on History Table.)  Note:  For the safety of the client all drugs used must be recorded in the client record.(See Manual for commercial names.)	Have You Ever Mis-Used/Bet	Age of First Use/Bet	Last Use/Bet	Freq of Last Use/Bet	Route of Admin Code	
		Y	N					
  A	Alcohol                                                                                               For Alcohol, enter first age of intoxication							
  B	Cocaine							
  C	Crack							
  D	Marijuana / Hashish							
  E	Heroin							
  F	Prescribed Opiates     Misuse/non-medical use of pharmaceutical opiates which were prescribed for the client.        							
  G	Non-prescribed Opiates  Non-medical use of pharmaceutical opiates which were not prescribed for the client							
  H	PCP							
   I	Other Hallucinogens							
  J	Methamphetamine							
  K	Other Amphetamines							
  L	Other Stimulants							
  M	Benzodiazepines							
  N	Other Tranquillizers							
  O	Barbiturates							
  P	Other Sedatives / Hypnotics							
  Q	Inhalants							
  R	Over the Counter							
  S	Club Drugs                                                       							
  U	Other							
  V	Fentanyl							
  X	Nicotine/Tobacco                                                              Includes cigarettes, cigars, chewing tobacco, inhalers							
  Y	Gambling                                                                                                        Includes  any of the types listed in Q.33a						N/A	
 Z	K2/Spice or Other Synthetic Marijuana							
	
	32a.  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).and go to Q32b
         If person does not use nicotine products, skip to Q33a   	
	32b.   Interest in stopping nicotine/tobacco use at Enrollment:  	
	 1No	 3Yes, Within 30 days	88Refused   	
	 2Yes, Within 6 Months	 4Does Not Apply (already stopped)	99Unknown	
	33a  Types of last regular gambling (check all that apply)  If person does not have a gambling history, skip to Q34    	
	Lottery -Scratch Tickets	Slot Machines	Sports Betting	Stock Market	
	Lottery - Keno 	Casino Games 	Bingo	Internet Gambling	
	Lottery/Numbers Games 	Card Games 	Dog/Horse Tracks, Jai Alai 		
	33b.  Have you ever thought you might have a gambling problem, or been told you might?       Yes       No     Refused     	

	Clients must be asked if they have a secondary and/or tertiary drug of choice.  Clinicians may rank substances based on their clinical opinion after review of the substance use history and not necessarily client report.
 (Nicotine/Tobacco and Gambling CANNOT be marked as a primary/secondary/or tertiary drug)	
	34.  Rank substances by entering corresponding letter for substances listed above in Question 31. (If no secondary or tertiary substance, leave blank)	
	       Primary Substance                             		                  Secondary Substance                                		Tertiary Substance		
	35.   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		
	36 Have you had any overdoses in your lifetime?*  Yes       No     (If No, skip to Q37)		
	    36a.   How many overdoses have you had in your lifetime? (1-99)
		36b.   How many overdoses have you had in past year? (0-99)		
	37.    Date of Drunk Driving Arrest 	             /           /				
	                                                                       mm         dd           yyyyy						
	38.    Referring Court:		
	39.    BAC this arrest:		
	40.    Lifetime number of arrests for DUI: 		
	41.    Lifetime number of DUI convictions:  		

	 Q 11 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)	99	Unknown	
04	8-15 times in past month (2 or 3 times per week)			

 Q 16   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. 21 Vision Impairment		Code	 Q. 22 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	  Q 23 Self Care/ADL  Impairment		Code	 Q. 24 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	

 Q 30: SUBSTANCE MIS-USE / NICOTINE/TOBACCO / GAMBLING HISTORY

Code	Last Use Substances		Code	Frequency of Last Use/bet		Code	Route of Administration	
1	12 or more months ago		1	Less than once a month		1	Oral (swallow and/or chewing)	
2	3-11 months ago		2	1-3 times a month		2	Smoking	
3	1-2 months ago		3	1-2 times a week		3	Inhalation	
4	Past 30 days		4	3-6 times a week		4	Injection	
5	Used in last week		5	Daily		5	Other	
			99	Unknown		6	Electronic Devices/Vaping