Enrollment Assessment
STR -RSC
	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 answer to Q14 is ‘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	

 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