Disenrollment Assessment
Opioid Treatment
	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.   Discharge Plan      01 Yes        02 No          	 4a. Referred to Self Help    01 Yes      02 No          	
	4b. Frequency of attendance at self-help programs in the last 30 days or since admission if in treatment less than 30 days. (e.g. AA, NA)                                                                    	                                                                                         	
	5.  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	                           	
	                                                                                     
6.   Employment status at Disenrollment: 
                            If Unknown, use 99         	            
                	8.	 7.  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                                                   	
	8.   Number of arrests in the last 30 days or since Enrollment if in treatment less than 30 days. If Unknown, use 99	             
            	
     	9.   Indicate the Social or Health Service provided to clients during treatment – While in your Program. (enter a code 0,1,2 or 3  for each category)	

    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
(e.g. Assistance with Court Issues)			Medication for Emotional Problem
 (i.e. Psychotropic Medication )			Literacy Services			Medication for Withdrawal
Not comfort meds (e.gTylenol)		
Drug Screening  (e.g. urine testing)			Housing
Perm/trans Housing not Tx			English as a 2nd  Language			TB Testing
Not screening or assessment
     (e.g a mantoux test is TB testing)		
Treatment for Medical Problems			GED			Job Placement/Referral
        (e.g. Resume writing)			TB Treatment
Medication		
Treatment for Emotional Problems
Mental Health not Addiction Issues			Vocational Training
(e.g. Nurses’ aid certification)			Financial Counseling
(e.g. Balance a checkbook)			STD/STI, HIV, Hep C Testing
Not screening or assessment		
Nicotine Replacement Therapy
(e.g. Patch, Gum)			Family Planning
(e.g. Birth Control Education)			Prenatal Care			STD/STI, HIV, Hep C Treatment
Medication		
Medication for Medical Problems			Child Care			Post-partum Care
Immediately after birth to 1 yr			
Parenting Classes
		
	10. 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. HIV, WIC not BSAS	 MRC: Mass Rehab	  Other	
 DYS:  Dept Youth Services	 DMH:  Dept Mental  Hlth	  DTA:   food stamps, TANF      	 MCB: Comm for the Blind		
   11.  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-Q H3 are required. If ‘No’, skip to Q12	
	H2.  Detailed living arrangement at Disenrollment                                      	                	
	H3.  Permanence Of living situation at Disenrollment*	 Permanent	  Transitional	 Refused	  Unknown	
     12.   Has there been any drug or alcohol use in the last 30 days or since Enrollment if in treatment less than 30 days?
                   If answer to Q12 Is ’No’, skip to Q 16a      	 Yes       No     	
	If Yes to Q12, please rank substance abuse problems by selecting the CURRENT primary, secondary, and tertiary substance. Enter  the corresponding letters A-U+Z.  (Neither nicotine/tobacco nor gambling are excluded).    If “Yes” Q13a Q14 & Q15 are required	
	Report the Frequency of Use in the last 30 days or since Enrollment if in treatment less than 30 days.  For these fields, enter corresponding code from list on next page.	
	   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                           	      	
	16a. Did the client use Nicotine/Tobacco since Enrollment    Yes     No     Refused     Unknown  
     If the answer is Yes to Q 16a. answer Qs 16b – 16d.	
	16b. Number of cigarettes currently smoked per day? (Indicate number of cigarettes, not number of packs: 1 pack = 20 cigarettes):
        If the client uses another type of nicotine/tobacco product, mark Zero (0) and go to Q 16c.		
	16c. Interest in stopping nicotine/tobacco use at Disenrollment:  	
	 1No	2Yes, Within 6 Months	 3Yes, Within 30 days     	4Does Not Apply (already stopped)	88Refused    	99Unknown	
	16d. While in this program, did the client attempt to stop using nicotine/tobacco?   01Yes       02No      88Refused     99Unknown	
	MTQAS/OPIOID QUESTIONS	
	   1.    Does/Did client have a current prescription opiate(s) upon leaving the program?  	                   1Yes       2No	
	 2.   Does/Did the client have a current prescription for Benzodiazepine(s) upon leaving the program?      1Yes       2No	
	 3.   Urinalysis Results Received Over the Past 3 Months.  EXCLUDE the client's initial urine screen 	
	Drug	# of Urine Screens for Drug	# of Testing Positive for Drug	
	Cocaine			
	Opiates			
	Methadone			
	Benzodiazepines			
	Other Drugs			
	4. Which medication-assisted treatment is the client currently using?     Methadone	 Buprenorphine           Injectable Naltrexone
     If client is currently using injectable naltrexone, skip Q4a  and go to Q5		
	 4a. Client's last dose before Disenrollment (mg)*: 	
	 5.   In what phase of treatment was the client?	
	1Assessment                     	2Active treatment		3Stabilization treatment   	4Medically supervised withdrawal	5Medical maintenance	

	 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 14a – 16c  	
 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	
		 Z	K2/Spice or Other Synthetic Marijuana		3	Inhalation	
					4	Injection	
					5	Other	
					6	Electronic Devices/Vaping