Disenrollment Assessment
STR-Recovery Support Center	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           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.  Number of arrests in the last 30 days or since Enrollment if in treatment less than 30 days.	             
            If Unknown, use 99	

	 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	16	 Recovery Support Center	51	Community or Religious Organization	
95	Referral Not Needed – Appropriate Mental Health Clinical Services Already in Place	17	Second Offender Aftercare	59	Drug Court	
96	Referral Not Needed – Appropriate Substance Abuse Clinical Services Already in Place	18	Family Intervention Programs	64	Prerelease, Legal Aid, Police	
97	Referral Not made – Client Dropped Out	19	Other Substance Abuse Treatment	68	Office of the Commissioner of Probation	
98	Referral Attempted – Not Wanted by Client	20	Health Care Professional, Hospital	69	Massachusetts Parole Board	
01	Self, Family, Non-medical Professional	21	Emergency Room	70	Dept. of Youth Services	
02	BMC Central Intake/Room 5	22	HIV/AIDS Program	71	Dept. of Children and Families	
03	ATS/Detox	23	Needle Exchange Program	72	Dept. of Mental Health	
04	Transitional Support Services/TSS		24 through 25 Discontinued	73	Dept. of Developmental Services	
05	Clinical Stabilization Services/CSS-CMID	26	Mental Health Care Professional	74	Dept. of Public Health	
06	Residential Treatment		27 through 29 Discontinued	75	Dept. of Transitional Assistance	
07	Outpatient SA Counseling	30	School Personnel, School System/College	76	Dept. of Early Education and Care	
08	Medication Assisted Treatment	31	Recovery High School	77	Mass. Rehab. Commission	
09	Drunk Driving Program		32-39 Discontinued	78	Mass. Commission for the Blind	
10	Acupuncture	40	Supervisor/employee Counselor	79	Mass. Comm. For Deaf & Hard of Hearing	
11	Gambling Program		41 through 49 Discontinued	80	Other State Agency	
14	Sober House	50	Shelter	81	Division of Medical Assistance/MassHealth	
				99	Unknown	
 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