Enrollment Assessment
        Opioid Treatment
	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): .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 Grp home	
	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  	
	  7.  Do you consider yourself to be transgender?                     Yes    No    Refused       	
	        7a.  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    Number of days between initial contact with program by client or someone on behalf of client and the first available appointment :    
         See Manual to help determine wait time.                                                                                                                                 (unknown = 999)                                                           	
	                                                               
    10.   Source of Referral:		
	                                                                                                                                                                                                                  
    11.  Frequency of attendance at self-help programs (e.g. AA, NA) in 30 days prior to Enrollment:                      		
	 12.  Additional Client Type: Answer Yes or No to a-j	
	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    			

	13.  Do you have children? 	   Yes      No     Refused         	If answer to Q13 is ‘Yes’, complete 13a-13d. If no, skip to Q14	
	      13a. Number Children Under 6:		   13b. Number of Children  6-18:		13c. Children Over 18:		
	      13d. Are any of the children of the Native American Indian race?	 1Yes       2No   	
	14.  Are you the primary caregiver for any children?   If yes, see manual	 Yes       No     Refused          	
	15.  Employment status at Enrollment:	              	16. Number of days worked in the past 30 days?		
	17.   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	
	18.  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	
	19.  Use of mobility aid: (Check all that apply)	 None	 Crutches	 Walker	  Manual Wheelchair	 Electric Wheelchair	
	20. Vision Impairment	                 		      	21. Hearing Impairment  	         			
	22. SelfCare/ADL Impairment	     			23. Developmental Disability	         			
	24.  Prior Mental Health Treatment:	0  No history        	1  Counseling	2  One  hospitalization	3  More than one  hospitalization	
	25.  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 	
	26.  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		
	27.  Currently receiving services from a state agency: (Check all that apply)  	
	  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		
	28.  Number of arrests in the past 30 days?                       		(Section 35 is not an arrest, it is a civil commitment)	

	29.  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							
  X	Nicotine/Tobacco                                                            Includes cigarettes, cigars, chewing tobacco, inhalers							
  Y	Gambling                                                                                                    Includes  any of the types listed in Q.31a						N/A	
  Z	K2/Spice or Other Synthetic Marijuana							
	
	30a.  Number of cigarettes currently smoked per day  (Indicate number of cigarettes, not number of packs:  1 pack = 20 cigarettes 0.)         
         If client uses another type of nicotine/tobacco product, mark Zero (0)  and go to Q30b
          If person does not use nicotine, skip to Q31a	
	30b.   Interest in stopping nicotine/tobacco use at Enrollment:  	
	 1No	 3Yes, Within 30 days	88Refused   	
	 2Yes, Within 6 Months	 4Does Not Apply (already stopped)	99Unknown	
	31a  Types of last regular gambling (check all that apply)  If person does not have a gambling history, skip Q33a and Q33bb  and go 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 		
	31b.  Have you ever thought you might have a gambling problem, or been told you might?       Yes       No     Refused     	

	Clinicians may rank Secondary and Tertiary substances based on their clinical judgement, after review of the substance use history not just client report. (Nicotine/Tobacco and Gambling CANNOT be marked as a primary/secondary/or tertiary drug)	
	32.  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		
	33.   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		
	34 Have you had any overdoses in your lifetime?*  Yes       No     (If No, skip to MTQAS questions)		
	  34a.   How many overdoses have you had in your lifetime? (1-99)
		34b.   How many overdoses have you had in past year? (0-99)		
	MTQAS/OTP Questions	
	  1.   Is your current methadone treatment for detoxification or maintenance?        Maintenance     Detoxification    	
	  2.   Do you have a current prescription for buprenorphine (Suboxone) or extended release injectable naltrexone (Vivitrol)?        Yes    No   
      (If Yes, Q2a and Q2b are required.	
	2a If yes, select the medication prescribed.
                Buprenorphine (Suboxone)  Extended release injectable naltrexone (Vivitrol)	
	2a. Is this prescription for alcohol use disorder, opioid use disorder, or both?
         Alcohol use disorder    Opioid use disorder    Both	
	3. Current Criminal status:	       None 	 Probation	 Parole       	 In Jail 	 On Bail     	
	4. Number of arrests in lifetime: (0-99):			
	5. Frequency of injected drug use in the past 12 months	
	1  None	3  1-3 times per month	5    3-6 times per week	
	2  Less than once per month	4  1-2 times per week	6   Daily	
	6. In general, how would you describe your current health?			
	1  Excellent	2  Very Good  	3  Good	4  Fair		5  Poor	
	7. During the past 12 months, how much difficulty did you have doing your daily activities, both inside and outside the home, due to physical or 
    emotional problems?	
	 None		 A little bit		 Some	 Quite a bit	 Unable to do daily activities	
	8.  During the past 12 months, how many nights were you hospitalized for physical problems?  (0 -366):	
	9.  During the past 12 months, how many nights were you in a detox facility? (0 -366):	
	10. During the past 12 months, how many visits to an emergency room and/or urgent care facility did you make? (0 -100):	

	11. In the past 12 months, how much were you distressed (bothered) by...	
		1  Not at all	2  A little/slightly	3  Moderately	4  A lot/extremely	
	a. Nervousness or shakiness inside?					
	b. Suddenly being scared for no reason?					
	c. Feeling fearful?					
	d. Spells of terror or panic?					
	e. Feeling that something bad is going to happen?					

	12. In the past 12 months, how much were you distressed (bothered) by...	
		1  Not at all	2  A little/slightly	3  Moderately	4  A lot/extremely	
	a. Blaming yourself for things?					
	b. Feeling blue?					
	c. Worrying too much about things?					
	d. Feeling no interest in things?					
	e. Feeling hopeless about the future?					
	e. Feeling hopeless about the future?					
	g. Feeling guilty for things that may not be your fault?					
	13.   Did you stay overnight somewhere for treatment of problems with your emotions, nerves, or mental health?*          	1 Yes     2No	
	14.   Did you ever get outpatient treatment or counseling for an emotional or mental health problem?*	1 Yes     2No	
	15.    In the past 12 months, did you think about suicide?*	1Yes	 2 No	
	16.    In the past 12 months, did you attempt suicide?	1 Yes	 2 No	
	17.   How supportive would you say the people closest to you are of your seeking substance abuse treatment at this time?	
	1 Not supportive or opposed	2 Not very supportive	3 Somewhat supportive	4 Very supportive	
	18.   Would you say that none of the people, a few of the people, or most of the people you are close to are currently abusing drugs?	
	1 None	2 One or a few	3 Most		

 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	26	Mental Health Care Professional	71	Dept. of Children and Families	
06	Residential Treatment		27 through 29 Discontinued	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	99	Unknown	
24	Sec 35 Bridgewater MASAC		52 through 58 Discontinued			
25	Sec 35 Framingham MCI	59	Drug Court			
	13 Discontinued	60	Court - Section 35			
14	Sober House		61 & 62 Discontinued			
15	Information and Referral	63	Court - Other			
16	Recovery Support Centers	64	Prerelease, Legal Aid, Police			
17	Second Offender Aftercare	65	County House of Corrections/Jail			
18	Family Intervention Program	66	Office of Community Corrections			
19	Other Substance Abuse Treatment					

	 Q 121Frequency 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 15.  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. 20 Vision Impairment		Code	 Q. 21 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 22 Self Care/ADL  Impairment		Code	 Q. 23 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 29:  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