Disenrollment Assessment
Residential	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.   Client Type          Primary      Collateral   	  4.   Discharge Plan  1Yes             2No          	
	5a. Referred to Self Help    1Yes      2No          	  	
	5b. 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)                                                                    	                                                                                          	
	6.  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	                           	
	                                                                                     
7.   Employment status at Disenrollment: 
             If Unknown, use 99         	    	8.	 8.  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.	
	9.  Are you currently pregnant or have you been pregnant in the past 9 months or since enrollment
     if in treatment less than 9 months? (Answer yes if either of these is true)	 Yes       No     	
	10.  Number of arrests in the last 30 days or since Enrollment if in treatment less than 30 days.	             
            If Unknown, use 99	
Collateral Stops Here
	11.   Were you receiving Medication Assisted Treatment BEFORE enrollment into this program?
         If Yes, answer Q11a -Q11d. If no, skip to Q12	 Yes       No     	
	11a. Did you continue to receive Medication Assisted Treatment while in this program?	 Yes       No     	
	11b. Were you receiving Methadone Treatment  If Yes skip to Q12 , If No answer 11c-11d	 Yes       No     	
	11c. Were you receiving a prescription for Suboxone or Vivitrol?   Select Below
       Buprenorphine (Suboxone)             Extended release injectable naltrexone (Vivitrol)		
	11d. Was your Suboxone or Vivitrol prescription for alcohol use disorder, opioid use disorder, or both?
       Alcohol Use Disorder           Opioid Use Disorder                        Both		
	Q12 – Q12c are not required if answered Yes to Q11		
	12.   Did you START Medication Assisted Treatments while in this program?  If No, skip to Q12	 Yes       No     	
	12a. Did you receive Methadone Treatment  if Yes, skip to Q12, if No answer 11b-11c	 Yes    No     	
	12b. Did you receive a prescription for Suboxone or Vivitrol?   Select Below      
        Buprenorphine (Suboxone)           Extended release injectable naltrexone (Vivitrol)		
	12c. Is your Suboxone or Vivitrol prescription for alcohol use disorder, opioid use disorder, or both?
       Alcohol Use Disorder           Opioid Use Disorder                        Both	
  13.   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		
	14. 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		
   15.  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 Q15	
	  H2.  Detailed living arrangement at Disenrollment                                       	                	
	  H3.  Permanence Of living situation at Disenrollment*	 Permanent	  Transitional	 Refused	  Unknown	
      16.  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 Q16 is ’No’, skip to Q120a     	 Yes       No     	
                If Yes Q16, 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 6   (nicotine/tobacco and gambling are excluded). If “Yes” to Q16: Q17a-c, Q18 and Q19 are required	
Report the Frequency of Use in the last 30 days or since Enrollment if in treatment less than 30 days.	
	17a. Primary Substance                             		17b. Frequency of Use                           	   	                     17c. Route of Administration                            		
	18.   Did the client use a Secondary Drug during the last 30 days/since Enrollment?     Yes      No       		
	8a. Secondary Substance                             		18b. Frequency of Use                             		18c. Route of Administration   		
	19.   Did the client use a Tertiary Drug during the last 30 days/since Enrollment?           Yes      No       		
	19a. Tertiary Substance                             		19b. Frequency of Use                             		19c. Route of Administration                           	        	
	20a. Did the client use Nicotine/Tobacco since Enrollment                 Yes       No    Refused     Unknown    
     If you answered Yes to Q20a, answer Q20b-d. If No, skip to Disenrollment Patient Placement Criteria	
	20b. 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)  		
	20c. Interest in stopping nicotine/tobacco use at Disenrollment:    		
	 1No	2Yes, Within 6 Months	 3Yes, Within 30 days     	4Does Not Apply (already stopped)	  88Refused    	99Unknown	
	20d. While in this program, did the client attempt to stop using nicotine/tobacco?          01Yes        02No    88Refused       99Unknown	

Massachusetts Residential Recovery Program - Disenrollment Patient Placement Criteria	
	Section 1: Acute Intoxication and/or Withdrawal Potential	
	Sobriety status is the outcome measure identified under this dimension. A "yes" response on any of these items indicates that the resident is not acutely intoxicated or at risk for physical withdrawal at the point of discharge. A "no" response on any of these indicates that the resident is acutely intoxicated or at risk of a physical withdrawal at the point of discharge and indicates the need of a more intensive level of care. The resident is not acutely intoxicated or at risk of physical withdrawal as evidenced by AT LEAST ONE of the following:	
		YES	NO	N/A		
	1a. Clean Urine Screens					
	1b. Stable Vital Signs					
	1c. Staff Observation					
	1d. Self report of no recent drug/alcohol abuse:					
	Section 2: Biomedical Stabilization	
	Answer all items in this section. Positive steps taken to improve health status is the outcome measure identified under this dimension. Any "no" response on the first 2 items indicates the need for a more intensive level of care. Starred (*) items indicate steps taken by the resident to address personal healthcare up to and including the point of discharge	
		YES	NO	N/A		
	2a. The Resident's biomedical condition is sufficiently stable as evidenced by the ability to participate in the essential components of a residential substance abuse program, AND*
					
	2b. The resident is demonstrating responsibility in matters of personal health care and is complying with the 
      prescribed course(s) of treatment					
	Behaviors consistent with biomedical stabilization may include the following outcome measures:					
	     *2-1. Resident has a primary care clinician					
	     *2-2. Resident has addressed necessary medical/health concern					
	     *2-3. Resident has begun the practice of health promotion activities					
	     *2-4. Resident has participated in health education groups, such as HIV education, smoking cessation, 
             nutrition, stress management, prenatal/postpartum.					
	Section 3: Behavioral Stabilization	
	Answer all questions in this section. Engaging in behaviors that are consistent with recovery goals is the outcome measure identified under this dimension. Any "no" response in the following 4 items indicates the need for a more intensive level of care that will address behavior issues. Starred (*) items indicate behavior change up to and including the point of disenrollment. The resident's behavioral conditions, and the achievement of recovery goals have been evidenced by the following:	
		YES	NO	N/A		
	3a. Resident has complied with the rules of the program AND					
	3b. Resident has progressed in achieving goals established in the treatment/service plan, AND					
	3c. Resident has changed behaviors in response to corrective action measures, AND					
	3d. Resident has demonstrated recovery based social functioning with community, staff, and peers.					

	Behaviors consistent with behavioral stabilization may include the following outcome measures:	YES	NO	N/A		
	     *3-1. Abstained from illicit and non-prescribed drugs/alcohol					
	     *3-2. Abstained  from illegal behavior (not including drug use)					
	     *3-3. Addressed pending legal issues					
	     *3-4. Addressed bad debts and/or financial obligations					
	
    *3-5. Changed other behavior in compliance with treatment/service plan					
	Section 4: Treatment Acceptance/Resistance	
	Any "no" response in this section indicates that the client does not accept treatment and provides documentation that the resident is no longer appropriate for placement in a Residential Recovery Program.	
		YES	NO	N/A		
	4a. The resident has participated in a recovery home environment that promotes recovery through peer 
      interaction, counseling, and educational forums, AND					
	4b. The resident has made the behavioral changes necessary for recovery as indicated in the treatment/service 
      plan, AND					
	4c. The resident has followed the rules and policies of the program.					
	4d. Other					
	Section 5: Relapse Potential	
	Answer all items in this section. Adoption of behaviors likely to reduce relapse potential are the outcome measures under this dimension. Any ''yes" response in the following 2 items indicates that relapse potential has been reduced in the Residential Recovery Home setting and the need for a structured residential program to address relapse potential has been eliminated. Starred (*) items that indicate behaviors that change on the part of the resident at the point of discharge. The resident relapse potential has been reduced by participants in residential treatment as evidenced by:	
		YES	NO	N/A		
	5a. Identification of relapse triggers, AND					
	5b. The development of alternative coping skills necessary to maintain recovery.					
	Behaviors consistent with a reduction in relapse potential may include one or more of the following:		
	     *5-1. Membership in 12-step or other self-help					
	     *5-2. Relaxation and/or meditation					
	     *5-3. Exercise					
	     *5-4. Religious/spiritual/faith community activity					
	     *5-5. Therapy					
	     *5-6. Relapse prevention group					
	     *5-7. Other					
	Section 6: Recovery Environment	
	Employment status, recovery supports, housing, and a safe post-discharge environment are the outcome measures identified under this dimension. Starred (*) items indicate the impact of the residential program on the development of a positive recovery environment.	
		YES	NO	N/A		
	6a. The resident has increased recovery potential by participating in planning for the development of a post-
      discharge occupation or activities in which recovery is supported.					
	6b. The resident has increased recovery potential by participating in the development of plans for the 
      development of a support network in the treatment programs and the community.					

	Behaviors consistent with the development of a support network may include one or more of the following:				
		YES	NO	N/A		
	   *6b-1. Involvement in the 12-step community					
	   *6b-2. Involvement in other self help					
	   *6b-3. Involvement in Smart Recovery					
	   *6b-4. Involvement in women for sobriety					
	   *6b-5. Support of family					
	   *6b-6. Moving into a 3/4 residential graduate program					
	   *6b-7. Moving into sober/supportive housing					
	   *6b-8. Attending, or scheduled to attend outpatient counseling, methadone, or acupuncture treatment.					
	   *6b-9. Involvement with alumni group					
	   *6b-10. Involvement with religious/spiritual/faith activities					
	
   *6b-11. Involvement in an environment that supports recovery					
	6c. The resident has increased recovery potential by participating in the development of plans for a safe post-
      discharge environment.					
	Behaviors consistent with development of a safe post-discharge environment may include ONE of the following:			
	  Living with family and/or independent housing					
	  Arrangements completed for cooperative housing					
	  Moving into 3/4 residential graduate program					
	  Moving into sober/supportive housing					
	  Arrangements completed for shelter					
	  Acceptance to live-in school					
	  Arrangements completed for another treatment environment					
	  Client walked away from program					
  	  Medical hospitalization transfer					
	  Psychiatric hospital transfer					
	  Incarcerated					
	  Died					
	  Other					
	  Unknown					

	 Q 5b  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 6. Referral at Disenrollment	

Code	 	

Code		Code		
00	Referral Not Needed – Assessment Indicates that Client Does Not Require Entering Formal Treatment	20	Health Care Professional, Hospital		67 Discontinued	
95	Referral Not Needed – Appropriate Mental Health Clinical Services Already in Place	21	Emergency Room	68	Office of the Commissioner of Probation	
96	Referral Not Needed – Appropriate Substance Abuse Clinical Services Already in Place	22	HIV/AIDS Program			
97	Referral Not made – Client Dropped Out	23	Needle Exchange Program	69	Massachusetts Parole Board	
98	Referral Attempted – Not Wanted by Client		24 through 25 Discontinued	70	Dept. of Youth Services	
01	Self, Family, Non-medical Professional	26	Mental Health Care Professional	71	Dept. of Children and Families	
02	BMC Central Intake/Room 5		27 through 29 Discontinued	72	Dept. of Mental Health	
03	ATS/Detox	30	School Personnel, School System/College	73	Dept. of Developmental Services	
04	Transitional Support Services/TSS	31	Recovery High School	74	Dept. of Public Health	
05	Clinical Stabilization Services/CSS-CMID		32-39 Discontinued	75	Dept. of Transitional Assistance	
06	Residential Treatment	40	Supervisor/employee Counselor	76	Dept. of Early Education and Care	
07	Outpatient SA Counseling		41 through 49 Discontinued	77	Mass. Rehab. Commission	
08	Medication Assisted Treatment	50	Shelter	78	Mass. Commission for the Blind	
09	Drunk Driving Program	51	Community or Religious Organization	79	Mass. Comm. For Deaf & Hard of Hearing	
10	Acupuncture		52 through 58  Discontinued	80	Other State Agency	
11	Gambling Program	59	Drug Court	81	Division of Medical Assistance/MassHealth	
	12 & 13 Discontinued		60– 63 Discontinued			
14	Sober House	64	Prerelease, Legal Aid, Police	99	Unknown	
	15 Discontinued		65-66 Discontinued			
16	New Recovery Support Center					
17	Second Offender Aftercare					
18	Family Intervention Programs					
19	Other Substance Abuse Treatment					
 Q.7 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 17a – 19c  	
 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			
H	PCP	R	Over the Counter		 Route of Administration	
I	Other Hallucinogens	S	Club Drugs 		1	Oral (swallow and/or chewing)	
J	Methamphetamine	U	Other		2	Smoking	
		V	Fentanyl		3	Inhalation	
		 Z	K2/Spice or Other Synthetic Marijuana		4	Injection	
					5	Other	
					6	Electronic Devices/Vaping