ESM Client ID:                                                        

WITS ID:

Intake	
ESM Release of Information:   Yes    No

Enrollment Date:               /            /
                                m m     dd      yyyy

	
		Transitional
Addiction
Treatment		
ALL QUESTIONS MARKED WITH A  MUST BE COMPLETED	

  	1. First  Name:	Middle Initial:	Last Name: 	Suffix:	
	2. Highest Grade Completed:	
		Not of school age		High school diploma/GED		College degree or higher		No formal education	
		Some schooling, no high school		Some college		Other credential (degree, certificate)		Unknown	
		Some high school		Associates degree					
	3. Gender:       Male  	Female  	Transgender  	4. Birth Date:	       /          /
mm    dd      yyyy	
	5. SSN:	If client refuses to give SSN or it is unknown, enter 999-99-9999 	
PERSONAL INFORMATION>ADDRESS 
	6a. Address Type:	Home    Near Homeless    Homeless     	See Job Aid in the Intake Manual to determine Homeless vs. non-Homeless!  	
                    If Address Type is “Homeless”, only enter the city/town and zip code where client is usually homeless. Do not use the Program’s city/town/zip.	
	 Street Address:	 	Unit:	
	 City/Town:	        	State:		Zip code:    	
	6b. Is this your Primary Address?  Yes   		
 ALTERNATE NAME Section
	If client has an alternate name, complete the following:				
	7a. First  Name:	Middle Initial:	Last Name: 		
            7b. Name Type:	 Alias    Nickname    Known by        Married Name     Maiden Name      Name at Birth        Prior Marriage Name 	
DEMOGRAPHICS>CULTURAL CHARACTERISTICS
	8a. Are you Spanish/ Hispanic/Latino?	Yes      No                                                    	
 If ‘yes’ to Question 8a, complete Question 8b.                               If ‘no’ to Question 8a, go to Question 9	
	
8b. Which of the following ethnicities best describes you?

______ Central American                                    ______  Mexican, Mexican American, Chicano              ______  South American
______ Cuban                                                     ______  Puerto Rican                                                      ______  Unknown
______ Dominican                                               ______  Salvadoran                                                        ______  Other, specify _____________________    
                                                                                                                               	
  If ‘no’ to Question 8a, Select one from below	
	9.  What is your primary Ethnicity/Ancestry?  (select one only)                                                                                                                 	
		African		Chinese		Latin American Indian	
		African American		Eastern European		Middle Eastern	

Client Demographics				 Intake Form

		American		European		Portuguese	
		Asian Indian		Filipino		Russian	
		Brazilian		Haitian		Thai	
		Cambodian		Japanese		Vietnamese	
		Cape Verdean		Korean		Unknown	
		Caribbean Islander		Laotian  		Other ,specify		

	10. What is your race?  (check all that apply)                                                                                                         	
		American Indian/Alaskan Indian		Native Hawaiian or Pacific Islander		Unknown	
		Asian		White		Refused	
		Black, African American		Other, specify:			
							
	11. In what language do you prefer to read or discuss health related materials?	
		American Sign Language		Haitian Creole		Russian	
		Cambodian (Khmer)		Hmong		Spanish	
		Cape Verdean Creole		Korean		Vietnamese	
		Chinese		Laotian 		Other, specify ______________________	
		English		Portuguese				
							
HOUSEHOLD CHARACTERISTICS Section
	12. Number of Adults in Household:
     (if client is Homeless, enter 1)	13. Number of Children Living in Household (children under 19):
     (children currently living with the client whether or not related)	
	14a. Client Income:   $	14b. Income Frequency:	 Weekly    Bi-Weekly    Monthly    Annually    	
	15. Source of Income:  (Check all that apply)			
	 	Wages/Salary		Veterans Disability Payment		Retirement - Social Security	
		Child Support		Private Disability Payment		Retirement/Pension - Private	
		Alimony		Public Assistance - TANF		Veterans Pension	
		Disability		Public Assistance - General		Non-employment Cash Income	
		Disability - SSI		Unemployment Compensation		None	
		Disability - SSIDI		Workers Compensation		Other	
							
	16. Marital Status:        Never Married         Married        Divorced         Widowed        Separated       Significant Partner Relationship.	
INSURANCE Section  (Data Entry: To get to Insurance section, return to Face Sheet and select Insurance link on left side of screen.)
       	17. Insurance Type:				
	 Uninsured	 MC  Medicaid / MassHealth /  MBHP	 MP   Medicare –Over 65-some disabled                	  VA   Veterans Administration  	
	 HM   Private HMO– through employment
                or client pay	 CI   Private Insurance–through employment or  
               client pay with no subsidy	 OT  Other-Includes ACA subsidy–ConnectCare or Health 
              SafetyNet                         	
	Insurance Company Name:                                                                                 Not required if uninsured	Policy Number:    
If Insurance Type is MC, the MassHealth Number must be entered, which begins with “100”.                                          	
	
Data Entry:
	If entering a New insurance record, enter the Enrollment Date as the Insurance Effective Date. 
If existing client with new insurance, end date previous insurance record with day before this Enrollment Date
If existing client and the insurance has Not Changed since the client’s last enrollment (whether or not at your program), simply hit SAVE.	
	18. Is this your Primary Insurance?	Yes     No  	
	If the client has additional insurance coverage, complete the following. If not, intake is complete.	
       	19. Insurance Type:  Note:  Uninsured is not an option under additional insurance.		
		 MC  Medicaid / MassHealth /  MBHP	 MP   Medicare –Over 65-some disabled                	  VA   Veterans Administration 	
	 HM   Private HMO– through employment
                or client pay	 CI   Private Insurance–through employment or  
               client pay with no subsidy	 OT   Other- Includes ACA subsidy–ConnectCare or Health
                SafetyNet                         	
	Insurance Company Name:                                                                               	Policy Number:    
If Insurance Type is MC, the MassHealth Number must be entered, which begins with “100”.                                          	
End of Intake

 	
ESM Client ID:                                                          

WITS ID:

Enrollment Date:               /            /
                             mm          dd          yyyy

	
		Enrollment 
TAT		

  	 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 put zip code of Program.  See Manual for definition of Permanent.	
	 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 Q. 7a, 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.   How did you learn about our program?		
	10.  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    			
	11.   Do you have children? 	        Yes      No     Refused     	If answer to Q11 is ‘Yes’, complete 11a-11d. If “No”, skip to Q12	
	11a. Number Children Under 6:		11b. Number of Children  6-18:		               11c. Children Over 18:		
	11d. Are any of the children of the Native American Indian race?	 1Yes       2No   	
	12.   Employment status at Enrollment:	         	13. Number of days worked in the past 30 days?		
	14.   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	
	15.   Who do you live with?  (Check all that apply)                    	
	    Alone	    Child 6-18	  Spouse/Equivalent	   Other Relative	
	    Child under 6	    Child over 18	  Parents	   Roommate/Friend	

	16.  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		
			
	17 Have you had any overdoses in your lifetime?*  Yes       No     (If No, skip to Q18)		
	    17a.   How many overdoses have you had in your lifetime? (1-99)
		17b.   How many overdoses have you had in past year? (0-99)		
	18.   Were you receiving Medication Assisted Treatment BEFORE enrollment into this program?
         If Yes, answer Q18a - Q18c. If NO, skip to Q19	 Yes       No     	
	18a. Were you receiving Methadone Treatment  (If Yes Enrollment Assessment complete , If No, answer Q18b-c                                                           	 Yes       No     	
	18b. Were you receiving a prescription for Suboxone or Vivitrol?   Select Below
      Buprenorphine (Suboxone)             Extended release injectable naltrexone (Vivitrol)		
	18c. Was this Suboxone or Vivitrol prescription for alcohol use disorder, opioid use disorder, or both?
           Alcohol Use Disorder              Opioid Use Disorder                        Both		
	Q19-Q19c are not required if Yes to Q18		
	19.   Did you START Medication Assisted Treatments while in this program?  If No, Enrollment Assessment is complete	 Yes       No     	
	19a. Did you receive Methadone Treatment if Yes, Enrollment Assessment is complete	 Yes    No     	
	19b. Did you receive a prescription for Suboxone or Vivitrol?   Select Below      
          Buprenorphine (Suboxone)           Extended release injectable naltrexone (Vivitrol)		
	19c. Is this Suboxone or Vivitrol prescription for alcohol use disorder, opioid use disorder, or both?
           Alcohol Use Disorder              Opioid Use Disorder                        Both	
	
                                               Disenrollment
                                                               TAT	

	Disenrollment Date:  	           /              /		   Intake/Clinician Initials              		
		mm          dd           yyyy				
 Disenrollment Reason:  Select one 	
	 Referred to Acute Treatment Svc (Detox)            		 Referred to Injectable Naltrexone Tx  (e.g. Vivitrol)	
	 Referred to Clinical Stabilization Svc (CSS)		 Referred to Emergency Department 	
	 Referred to SA Outpatient Tx 		 Referred to Mental Health Svc 	
	 Referred to Residential Tx 		 Referral Conditions Not Met	
	 Referred to Methadone Tx 		 Appropriate Service Not  Available	
	 Referred to Buprenorphine Tx  (e.g. Suboxone)		  Lost to follow-up	

 Q 9 How did you learn about our program?	

Code	 	

Code	Code	
01	Self, Family, Non-medical Professional	20	Health Care Professional, Hospital	67	Department of Corrections	
02	BMC Central Intake/Room 5	21	Emergency Room	68	Office of the Commissioner of Probation	
03	ATS/Detox	22	HIV/AIDS Programs	69	Massachusetts Parole Board	
04	Transitional Support Services/TSS	23	Needle Exchange Programs	70	Dept. of Youth Services	
05	Clinical Stabilization Services/CSS-CMID		24 through 25 Discontinued	71	Dept. of Children and Families	
06	Residential Treatment	26	Mental Health Care Professional	72	Dept. of Mental Health	
07	Outpatient SA Counseling	30	School Personnel, School System/Colleges	73	Dept. of Developmental Services	
08	Medication Assisted Treatment	31	Recovery High School		74 through 76 Discontinued	
09	Drunk Driving Program		32 through 39 Discontinued	77	Mass. Rehab. Commission	
10	Acupuncture	40	Supervisor/Employee Counselor	78	Mass. Commission for the Blind	
11	Gambling Program		41 through 49 Discontinued	79	Mass. Comm. For Deaf & Hard of Hearing	
	Note: Sec 35 Options are grouped although numbers are not in sequence. Select correct #	50	Shelter	80	Other State Agency	
12	Sec 35 (WATC & MATC)	51	Community or Religious Organization		81 Discontinued	
24	Sec 35 Bridgewater MASAC		52 through 58 Discontinued	99	Unknown	
25	Sec 35 Framingham MCI	59	Drug Court			
	13 Discontinued	60	Court - Section 35			
14	Sober House	63	Court - Other			
15	Information and Referral Helpline	64	Prerelease, Legal Aid, Police			
17	Second Offender Aftercare	65	County House of Corrections/Jail			
16	Recovery Support Centers	66	Office of Community Corrections			
18	Family Intervention Program					
19	Other Substance Abuse Treatment					

 Q 12   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