Apps.oasas.ny.gov



Provider Number __ __ __ __ __Program Number __ __ __ __ __Client ID __ __ __ __ __ __ __ __ __ __Special Project Code (See instructions): __ __ __85153595254004304800952500Sex Male Female Birth Date __ __/__ __/__ __ __ __ Last 4 SSN __ __ __ __ Last Name First 2 Letters __ __(Birth Name)48444151905004381500952500Admission Date __ __/__ __/__ __ __ __Significant Other Yes NoRaceHispanic Originleft6350003676650952500Alaska NativeCuban36766501397000left952500American IndianMexican36766501905000left952500AsianPuerto Rican 36766502857500left952500Black or African AmericanOther Hispanic36766503810000left952500Hawaiian or Other Pacific IslanderHispanic, Not Specified36766503810000left952500WhiteNot of Hispanic Originleft952500Other17716509525001144905762000Veteran StatusYesNoZip Code of Residence __ __ __ __ __ (If Canada, enter “88888”) County of Residence ____________________Type of Residence:20612109525004800600952500left952500Private ResidenceSingle Resident OccupancyOther Group Residential Setting20688309525004800600952500left952500Homeless, ShelterCD Community Residence/CongregateInstitution, Other (e.g., hospital)20688309525004800600952500left952500Homeless, No ShelterMH/DD Community ResidenceOtherPrincipal Referral SourceCriminal Justice Services Chemical Dependence Treatment (continued)36861751905000left1714500Gambling CourtCD Outpatient Rehab Programleft7620003686175952500Drug CourtCD Opioid Treatmentleft698500NYS Division of ParolePrevention/Intervention Servicesleft7620003686175952500Drinking Driver ReferralStudent Assistance Program (SAP)/School Basedleft1270003686175889000PoliceEmployee Assistance Programleft7620003686175952500Family Court/ProbationYouth Education and Intervention (non-SAP)left6985003686175889000Other Court/ProbationHospital and Health Care Intervention Servicesleft7620003686175952500Alternatives to IncarcerationOther Prevention/Intervention Programleft698500City/County JailHealth Care Services368617519050000000NYS Department of Correctional ServicesDevelopmental Disabilities Program368300024130000000Office of Children and Family ServicesMental Health Provider36835772159000Self, Family, Other Problem Gambling ServiceManaged Care Provider368357719050000-63500Self-ReferralHealth Care Provider368357716510Inde00Inde0000SpouseAIDS Related Services0-63500Family, Friends, Other IndividualEmployer/Educational/Special Services36861750000000GA/GamAnonEmployer/Union (Non-EAP)36835778890000-63500AA/NA and Other Self-HelpSchool (Other than Prevention Program)36835776350000000Problem Gambling Helpline Special Services (Homeless/Shelters)0-63500Financial CounselingSocial Services36957009525000000Crisis Services Local Social Services-Child Protect Services/CWA36957009525000000Problem Gambling Outpatient Service Local Social Services Dist-Income Maintenance369570019050000000PG Inpatient Program/Residential Local Social Services Dist Mandate/Public Assistance36957009525000000Other PG Program Local Social Services Dist Mandate/Medicaid Only3695700889000Chemical Dependence TreatmentOther Social Services Provider0000CD Medically Managed Detoxification0-63500CD Medically Supervised Withdrawal Inpatient/Res0-63500CD Medically Supervised Withdrawal Outpatient*****3705225635000 0-63500CD Med. Monitored Withdrawal/Part 820 StabilizationOther0000CD Inpatient Rehabilitation0-63500CD Intensive Residential/Part 820 Rehabilitation0000CD Residential Chemical Dependency for Youth0000CD Outpatient Chemical Dependency for Youth0-63500CD Community Residence/Congregate0000CD Outpatient ClinicHighest Grade Completedleft698500No Educationleft7620002200275952500526732595250012763509525001st6th11thSome College-No Degreeleft6985002200275889000526732588900012763508890002nd7thHigh School DiplomaAssociates Degree220027518097500220027588900052635152857500127635019050003rd8thGeneral Equivalency Diploma (GED)Bachelor’s Degreeleft127000220027517145000526732595250012763508890004th9thVocational Cert w/o Diploma/GEDGraduate Degreeleft76200012763509525005th10thVocational Cert w/Diploma/GEDEmployment Status4810125190500024384009525000000Employed Full Time-35+ hrs/wkNot in Labor Force, Child CareSocial Services Work Exp Program481012588900024384008890000-63500Employed Part-time <35 hrs/wkNot in Labor Force, DisabledUnable to Work, Mandated243840010160000000Employed in Sheltered WorkshopNot in Labor Force, In TrainingTreatment243840016510000-63500Unemployed in TreatmentNot in Labor Force, Retired24384008255000000Unemployed, Looking for WorkNot in Labor Force, Student24384008890000-63500Unemployed, Not Looking for WorkNot in Labor Force, OtherIndustry of Employmentleft69850043719758890002447925889000NoneTravel/HospitalityArchitecture/Construction/Real Estateleft76200043719759525002447925952500BusinessGovernmentAgricultureleft127000437197582550024479251016000ComputerMilitaryReligiousleft1905004371975171450024479251778000TelecommunicationsAerospaceSocial Servicesleft8890004371975177800024479251778000Financial ServicesHealth Care/MedicalSalesleft76200043719759525002447925952500ManufacturingInsurance/LegalGambling Industryleft6985002447925889000Wholesale/Retail/DistributionEducationleft7620002447925952500TransportationUtilities Annual Household Incomeleft76200038862009525001943100952500Less than $15,000$30,001 - $50,000$75,001 - $100,000left69850038862008890001943100889000$15,000 - $30,000$50,001 - $75,000More than $100,00061874402095500430149020955005273040209550029679902095500185356520955001066800952500Marital Status Married Never Married Living as Married SeparatedDivorcedWidowedReligious Preferenceleft9525002457450952500CatholicBuddhistleft6985002457450889000ProtestantAtheist/Agnosticleft95250024574501778000Other ChristianOtherleft12700024574501841500JewishNo Preferenceleft762000MuslimCriminal Justice Statusleft69850024707858255NoneProbation – ATIleft76200024650701143000Pre-Court Sentence (non ATI)Other Alternative to Incarcerationleft69850024707851016000Pre-Court Sentence – ATICorrectional-Based Setting2468880952500left762000Probation – non ATIPost Correctional SupervisionHas patient attended or received services for any reason from:59626510795000-63500YesNoGA/GamAnon5962651206500596265173990000000YesNoOther Problem Gambling Program0-63500YesNoFinancial and/or Credit Counseling ServiceType(s) of Gambling Engaged In (Must check one for each – Primary, Secondary, Tertiary)Primary025400 00 None15240000 Slot Machines952543180 00 Stock/Commodities Market07620 00 Cards152400 00 Roulette1397037465 00 Game of Skill for Money033020 00 Horses15240000 Video Lottery Terminal (VLT) (bowling, billiards, golf, etc.)035560 00 Dogs/Other Animals152402095500 Lottery (Numbers, Scratch Offs,952515240 00 Raffles (including 50/50)027940 00 SportsQuick Draw)1714528575 00 Office Pools030480 00 Dice Games (including craps, over and under, other dice games)1524010795 00 Bingo3302019050 00 Other Primary Frequency No use in last 30 days 1-3 times last 30 days 1-2 times per week 3-6 times per week DailyPrimary – Age First Gambled __ __Secondary025400 00 None15240000 Slot Machines952543180 00 Stock/Commodities Market07620 00 Cards152400 00 Roulette1397046990 00 Game of Skill for Money033020 00 Horses15240000 Video Lottery Terminal (VLT) (bowling, billiards, golf, etc.)035560 00 Dogs/Other Animals152402095500 Lottery (Numbers, Scratch Offs, 952515240 00 Raffles (including 50/50)027940 00 SportsQuick Draw)952522860 00 Office Pools030480 00 Dice Games (including craps, over and under, other dice games)1524010795 00 Bingo139709525 00 Other Secondary Frequency No use in last 30 days 1-3 times last 30 days 1-2 times per week 3-6 times per week DailySecondary – Age First Gambled __ __Tertiary025400 00 None15240000 Slot Machines952543180 00 Stock/Commodities Market07620 00 Cards152400 00 Roulette2349537465 00 Game of Skill for Money033020 00 Horses15240000 Video Lottery Terminal (VLT) (bowling, billiards, golf, etc.)035560 00 Dogs/Other Animals152402095500 Lottery (Numbers, Scratch Offs, 952515240 00 Raffles (including 50/50)027940 00 SportsQuick Draw)952522860 00 Office Pools030480 00 Dice Games (including craps, over and under, other dice games)1524010795 00 Bingo139700 00 Other Tertiary Frequency No use in last 30 days 1-3 times last 30 days 1-2 times per week 3-6 times per week DailyTertiary – Age First Gambled __ __During the past 30 days, what amount of money did you spend on a typical day of gambling? $__ __ __ __During the past 30 days, how much time did you usually spend on a typical day of gambling? __ __hrs __ __ min.During the past 30 days, on how many days did you gamble? __ __ daysGambling Locations(s) during the last 12 months (check all that apply)left12700043719758890002447925889000None (Significant Other Only)Off-Track Betting (OTB)Homeleft76200043719759525002447925952500CasinoBookieChurch/Community Site4371975825500left69850024479251016000Race TrackBar/RestaurantOtherleft76200024479251778000Grocery/Convenience StoreWorkleft69850024479251778000InternetSchoolType(s) of Presenting Gambling-Related Problems at Admission (Check all that apply)481012538100024384009525000000Employment/EducationSignificant DebtAnxiety480631576200024384008890000-63500Marital or Relationship ProblemsEmbezzlementOther Mental Health Problems4810125952500243840010160000000BankruptcyPhysical Health ProblemsOther Legal2438400148030002438400889000481012510160000-63500Borrowing or Theft from Relatives/Suicidal Ideation/Thoughts/AttemptsArrest48063151016000FriendsDepressionIncarceration0000Losing Savings/RetirementSubstance Abuse (Must check one for each – Primary, Secondary, Tertiary – if no substance abuse, check “None” for each)Primary Substance None OxyContin GHB Other Hallucinogen Alcohol Other Opiate/Synthetic Khat Ephedrine Cocaine Alprazolam (Xanax) Other Tranquillizer Inhalant Crack Barbiturate Methamphetamine Ketamine Marijuana/Hashish Benzodiazepine (Klonopin) Other Amphetamine Rohypnol Heroin Catapres (Clonidine) Other Stimulant Over-the-Counter Buprenorphine Other Sedative/Hypnotic PCP Other Non-Rx Methadone Elavil EcstasyPrimary Route Inhalation Injection Oral Smoking OtherPrimary Frequency No use in last 30 days 1-3 times last 30 days 1-2 times per week 3-6 times per week DailyPrimary Age of First Use __ __Secondary Substance None OxyContin GHB Other Hallucinogen Alcohol Other Opiate/Synthetic Khat Ephedrine Cocaine Alprazolam (Xanax) Other Tranquillizer Inhalant Crack Barbiturate Methamphetamine Ketamine Marijuana/Hashish Benzodiazepine (Klonopin) Other Amphetamine Rohypnol Heroin Catapres (Clonidine) Other Stimulant Over-the-Counter Buprenorphine Other Sedative/Hypnotic PCP Other Non-Rx Methadone Elavil Ecstasy221551512065003939540120650032632651206500482536512065001152525889000Secondary Route InhalationInjectionOralSmokingOtherSecondary Frequency No use in last 30 days 1-3 times last 30 days 1-2 times per week 3-6 times per week DailySecondary Age of First Use __ __Tertiary Substance None OxyContin GHB Other Hallucinogen Alcohol Other Opiate/Synthetic Khat Ephedrine Cocaine Alprazolam (Xanax) Other Tranquillizer Inhalant Crack Barbiturate Methamphetamine Ketamine Marijuana/Hashish Benzodiazepine (Klonopin) Other Amphetamine Rohypnol Heroin Catapres (Clonidine) Other Stimulant Over-the-Counter Buprenorphine Other Sedative/Hypnotic PCP Other Non-Rx Methadone Elavil Ecstasy221551512065003939540120650032632651206500482536512065001152525889000Tertiary Route InhalationInjectionOralSmokingOtherTertiary Frequency No use in last 30 days 1-3 times last 30 days 1-2 times per week 3-6 times per week DailyTertiary Age of First Use __ _________________________________________________________________________________________________________Nicotine6073140889000545782588900023488658890001781175889000Smoked tobacco in last week: Yes NoUsed smokeless tobacco in last week: Yes No_______________________________________________________________________________________________________Mental Health-Related Conditions63493651333500580644013335003310890133350027622501778000Intellectual Disability/Developmental Disability Yes NoCo-existing Psychiatric Disorder Yes NoHistory of Mental Health Treatment43776906985003701415168910003705225889000Ever Treated for Mental Illness YesNo4377690762000370141516002000Ever Hospitalized for Mental Illness ProblemYesNo4377690889000Ever Hospitalized 30 or More Days for Mental Illness ProblemYesNo______________________________________________________________________________________________________Score on Admission Administration of the DSM V Gambling Disorder Form: __ __Date of Admission Administration __ __/__ __/__ __ __ __ ................
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