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Shelter & Detox FormFirst Name (or initial): ________________Last Name (or initial): ________________Gender: Male | Female | Transgender-Male | Transgender-FemaleDOB: _________SSN (all or last 4): __________________Consent Decree Member: Yes | NoEthnicity: Not Hispanic | Puerto Rican | Mexican | Cuban | Other Specific Hispanic | Specific Origin Not SpecifiedRace: 01-White | 02-Black/African Amer. | 03-Amer. Indian/Alaskan Native | 04-Asian | 05-Native Hawaiian/PI | OtherVeteran Status: Yes | NoIntake Facility: ______________________________Intake Staff: ________________________________County: _______________________________*Referral: ___________________________________Initial Contact Date: _________________Intake Date: _______________________Pregnant (if female): Yes | NoIf Yes, Due Date: ___________ If Yes, Prenatal Care: Yes | No___HIV Positive: Yes | No | UnknownHepatitis C Positive: Yes | No | UnknownInjection Drug Use: Never | In Last 6 Mos. | In Last 5 Years | Prior to last 5 yearsIf IDU, Did Client share needles in past year _________Problem Area: 01-Substance Abuse02-Affected Other03-Evaluation OnlyAdmission Type: Shelter & DetoxAdmission Date: ________________Affected/Co-dependent: Yes | No# Prior SA Tx. Admissions: __________MH/MR Diagnosis: 00-None | 01-Diagnosed Mental Illness | 02 Mental Retardation | 97-UnknownEducation Level: ______________*Employment Status: ________________*Primary Income Source: _____________________*Insurance Type: ___________________________*Living Arrangements: ____________________________*Marital Status: ____________________________________Substance (Primary): _____________ Frequency: ____________ Method: ___________ Age 1st Used: _____Substance (Secondary): _____________ Frequency: ____________ Method: ___________ Age 1st Used: _____Substance (Tertiary): _____________ Frequency: ____________ Method: ___________ Age 1st Used: _____*Medication Assisted Treatment: __________________Does Client currently use Tobacco? __________ If yes, age of 1st use: ________ Method: ____________If Yes, Frequency: ? pack/can a day | 1 pack/can a day | 1 ? pack/can a day | 2 pack/can a day | More*Legal Status: ________________________Arrests past 12 months: _____Arrests past 30 days: ______# OUI Arrests past 12 months _______Program Enrollment: _________________*Answer values not listed on the front page Referral01 - Self02 - Family Member03 - Employer04 - Substance Abuse Professional – (Private Practice)05 - Substance Abuse Agency06 - Physician (Non-Substance Abuse Specialist)07 - Other Professional (Non-Substance Abuse Specialist)08 - DEEP (Driver Education/Evaluation Program)09 - Adult Protective Services, DHHS10 - Child Protective Services, DHHS11 - Substitute Care Services, DHHS12 - Probation/Parole, State of Maine13 - Correctional Facility, State of Maine14 - County Jails15 - Augusta/Bangor Mental Health Institute16 - Mental Health Agency17 - Friend18 - EAP19 - SAP20 - State/Federal Court21 - Formal Adjudication Process22 - Self-Help Group23 - Hospital24 - School25 - AIDS Outreach Worker26 - Community Probation, DSAT27 - Drug Court, DSAT28 - Network/JASAE29 - Juvenile Drug Court30 - Physician/PMP31 - Hospital/PMP99 – OtherDetailed Drug CodesAlcohol - 0100 AlcoholMarijuana0200 Marijuana0250 Synthetic Cannabis (K2/Spice)Cocaine/Crack0301 Cocaine0302 CrackHeroin/Morphine - 0400 Heroin/MorphineMethadone/Buprenorphine0500 Methadone0550 Buprenorphine/Suboxone/SubutexOther Opiates and Synthetics0601 Codeine0602 D-Propoxyphene0603 Oxycodone (Percodan)0604 Oxycontin0605 Meperidine HCL0606 Hydromorphone0607 Other Narcotic Analgesics0608 PentazocinePCP - 0700 PCP or PCP CombinationOther Hallucinogens0801 LSD0802 Other HallucinogensMethamphetamine/Speed 0900 Methamphetamine/SpeedOther Amphetamines1001 Amphetamine1002 Methylphenidate (Ritalin)1003 Methylenedioxymethamphetamine(MDMA, Ecstasy)Other Stimulants1100 Other Stimulants1809 Bath SaltsBenzodiazepines1201 Alprazolam (Xanax)1202 Chlordiazepoxide (Librium)1203 Clorazpate (Tranzene)1204 Diazepam (Valium)1205 Flurazepam (Dalmaine)1206 Lorazepam (Ativan)1207 Triazolam (Halcoin)1208 Other BenzodiazepineOther Tranquilizers1301 Meprobarnate (Miltown)1302 Other TranquilizersBarbiturates1401 Phenobarbital1402 Secobarbital/Amobarbital (Tuinal)1403 Secobarbital (Seconal)Other Sedatives and Hypnotics1501 Ethchlorvynol (Placidyl)1502 Glutethimide (Doriden)1503 Methaqualone1504 Other Non-Barbiturate Sedatives1505 Other Sedatives1506 Flunitrazepam (Rohypnol)1507 GHB/GBL1508 Ketamine (Special K)1509 Clonazepam (Klonopin, Rivotril)Inhalants1601 Aerosols1602 Nitrites1603 Other Inhalants1604 Solvents1605 AnestheticsOver the Counter1700 Over the counter, General1701 Diphenhydramine (Benadryl)Other1801 Diphenylhydantoin Sodium(Phenytoin, Dilantin)1802 Other DrugsEmployment StatusFull Time (35 hrs or more)Part Time (17-34 hrs)Irregular (< 17 hrs)Unemployed (Has sought work)Unemployed (Hasn’t sought work)Not in Labor ForceFull Time VolunteerPart Time VolunteerIrregular VolunteerInsurance Type:Private InsuranceBlue Cross/Blue ShieldMedicareMainecare MEDICAID)HMOOtherNoneLiving Arrangement: Independent, Living AloneIndependent, Living W OthersDependent LivingHomelessMarital Status: Never MarriedMarried/PartneredSeparatedDivorcedWidowedPrimary Income Source01 - None02 – Wages/Salary03 – Alimony04 – Food Stamps05 – TANF06 – SSI07 - Disability, Other08 – Town Welfare09 – Child Support10 – Unemployment11 – Social Security12 – Dealing Drugs13 – Workers Compensation99 – Other/InvestmentsMAT:NOMETHADONEBUPRENORPHINE/SUBOXONE/SUBUTEXCAMPRALNALTREXONEVIVITROLANTABUSELegal Status:No Legal InvolvementProbation/ParoleFurloughedAwaiting CourtServing Sentence/Jail PrisonFormal AdjudicationDriver’s License revocation (Not DEEP involved)OtherExpected Payment Source01 - SAMHS (OSA)02 - Human Services (other than Child, Adult protective)03 - Corrections04 - Human Services (Adult or Child Protective)05 - Self Pay06 - MaineCare (Medicaid)07 - Medicare08 - Blue Cross/Blue Shield09 - HMO10 - Other Private Health Insurance11 - Town Assistance12 - Workers’ Compensation13 - Veterans’ Administration99 - Other ................
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