Enrollment Assessment
Standard
	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:		
	                                                                                                                                                                                              
  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 ‘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)                    	
	    Alone	    Child 6-18	  Spouse/Equivalent	   Other Relative	
	    Child under 6	    Child over 18	  Parents	   Roommate/Friend	
COLLATERAL CLIENTS STOP HERE
	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 . 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)  See manual for definitions	
	  None	  DMH client has a case mgr.	  DTA e.g. food stamps	  MCDHH services for Deaf and Hard of Hearing 	
	  DCF children and families 	  DDS developmental disabilities	  MRC Rehabilitation Commission	  Other 	
	  DYS youth services	  DPH e.g. HIV/STD; not BSAS .	  MCB services for the 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 Q33a						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). 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, Assessment is complete)	
	   36a. How many overdoses have you had in your lifetime? (1-99)
		36b. How many overdoses have you had in past year? (0-99)		

 Q10. Source of Referral at Enrollment	

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	64	Prerelease, Legal Aid, Police			
17	Second Offender Aftercare	65	County House of Corrections/Jail			
16	New Recovery Support Centers	66	Office of Community Corrections			
18	Family Intervention Program					
19	Other Substance Abuse Treatment					

	 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