Njsams.rutgers.edu



Department of Human Services (DHS)

Division of Mental Health and Addiction Services (DMHAS)

Office of the Research, Planning, Evaluation, Information Systems and Technology

Data Entry form on Paper

For the

NEW NJSAMS Admission Module

(Please download and keep extra copies at all time in case of Internet Connection failure and System unavailable)

NJSAMS Real-time Data System (Do not use training or demo. purposes)



If you have any questions please call customer service at

Phone: 609-777-2164

Updated 11/28/2014/kkh

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CLIENT ADMISSION FORM IN NJSAMS

Admission Detail/Referral Source

Client’s:

________________ ___________ ____________________

First name Middle name Last name

Date of Admission: _________________________

Site: ______________________________

MClient ID (For Methadone Provider): ________________________

Client Type: Alcohol/Drug Abuser

Co-Dependent/Family (Non Substance Abuser)

Referral Source:-

Self

Family/Friend

Intoxicated Drivers Resource Center (IDRC)

Employee Assistance Program

Hotline

Other|

Outreach

Syringe Exchange Program (DOH)

Community Services

SBIRT - HJA

Addiction Services – Addiction Treatment Program

Addiction Services – County Drug and Alcohol Coordinator

Addiction Services – South Jersey Initiative

Addiction Services – Other

Corrections Related Programs – Municipal Court

Corrections Related Programs – COUNTY – Family Court

Corrections Related Programs – COUNTY – Drug Court

Corrections Related Programs – COUNTY – Probation

Corrections Related Programs – COUNTY – Detention Center

Corrections Related Programs – COUNTY – Other|

Corrections Related Programs – STATE – NJ State DOC

Corrections Related Programs – STATE – NJ State Parole Board

Corrections Related Programs – FEDERAL – US Federal Prison

Corrections Related Programs – FEDERAL – US Federal Court

Corrections Related Programs – FEDERAL – Juvenile Justice

Commission (JJC)

Corrections Related Programs – Other

Mental Health – Mental Health Screening Center

Mental Health – Mental Health Provider/Clinic

Mental Health - Hospital

Mental Health - Other

Mental Health – MICA Program

Hospital ER/Ed

Medical/Health – County (or) Municipal Department

Medical/Health – Hospital Crisis Emergency Room

Medical/Health – Other Hospital

Medical/Health – Health Care Agency/Private Physician

Medical/Health – Other

Welfare/Social Services – NJ Dept. of Human Services

Welfare/Social Services – WFNJ Substance Abuse Initiative (SAI)

Welfare/Social Services – Substance Abuse Research Demonstration

Welfare/Social Services – Other

Child Protection Substance Abuse Initiative (CPSAI)

SBIRT

Level of Care (LOC)

1. Standard/Traditional Outpatient

2. Intensive Outpatient

3. Partial Hospitalization

4. Transitional Care/ Extended Care

5. Halfway House

6. Long-Term Residential

7. Short-Term Residential

8. Hospital-Based (acute) Residential

9. Detox-Free-Standing Residential (Sub-Acute)

10. Detox-Hospital Inpatient

11. Detox-Outpatient (Non-Methadone)

12. OPIOID Maintenance-Outpatient

13. Detox-Mehtadone Outpatient

14. Non-Traditional Program

15. OPIOID Maintenance-Intensive Outpatient

16. Early Intervention

Is the use of medication planned as part of treatment?

(check all that apply)

Methadone Buprenorphine Acamprosate

Naltrexone (oral) Vivitrol Psychotropic Medication

Other ________________________

No Don't Know

Client Detail

Living Arrangement::-

Dependent Living/Institution

Homeless-Shelter

Homeless-Streets

Independent Living

Length of Time at Current Address: ____ year(s) ______ month(s)

Is client a Veteran? No Yes

Is the client pregnant? No Yes Don't Know

Did client give birth in the past 12 months? Yes No

Does the client have any children 17 years or younger? Yes No

Is the client bringing dependent children into tx? Yes No

Is the Client Evacuee of Hurricanes?

1. Sandy 2. Irene 3. Katrina

Education / Employment

What is the highest grade completed in school? ______ (If none enter 0)

Does client have a high school diploma or GED? Yes No

Is client currently enrolled in school or a job training program?

1. Not enrolled (If not enrolled answer the following if applicable..)

Completed

Dropped Out

Expelled

Suspended

Medical Leave

Home Study

Other

2. Enrolled Full-Time

3. Enrolled Part-Time

4. Other

Which best describes your CURRENT employment situation?

1. Full-time work or military (35 hours a week or more)

2. Part-time

3. Student

4. Home Maker

5. Retired

6. Unemployed: Actively looking for work

7. Unemployed: Not looking for work

8. Unemployed: Volunteer work

9. Living in an institution, like a jailor prison, hospital or overnight

treatment program

10. Disable

Principal Source of financial support (check all that apply)

For children under 18 this field indicates the parent’s primary source of income/support

Wages/Salary

Public Assistance

Retirement/Pension

Disability

Other ________________

None

Legal Information / self-Help / Recovery Support

Legal Information

What is client’s Current Legal Status?

1. No Legal Problem

2. Case Pending

3. Drug Court

4. Probation

5. Parole

6. DWI License Suspension

7. Jail/Prison Inmate

8. DYFS or Family Court

9. Other

If other; Specify __________________

How many times has client been arrested and charged for an offense in the past 30 days? _______ Time(s)

Self-Help

In the past 30 days, did client attend any self-Help Groups? (Check all that apply)

Narcotics Anonymous (NA)

Alcoholic Anonymous (AA)

Any religious or faith affiliated recovery Self-Help Group

Other Self-Help/Mutual Support Groups

Frequency of attendance:

No Attendance in the past month

1-3 times in the past month (less than once per week)

4-7 times in the past month (about once per week)

8-15 times in the past month (2 to 3 times per week)

16-30 times in the past month (4 or more times per week)

Some attendance but frequency unknown in the past month

Unknown

Self-Help Groups ever participated in (check all that apply)

Narcotics Anonymous (NA)

Alcoholic Anonymous (AA)

Any religious or faith affiliated recovery Self-Help Group

Other Self-Help/Mutual Support Groups

Recovery Support

In the past 30 days, did client have interaction with family and/or friends that are supportive of his/her recovery?

Yes No Refused to answer Don’t know

To whom, does the client turn to when he/she is having trouble that is supportive of his/her recovery?

No One Counselor Clergy Family Member Friends

Other _____________ Refused to answer Don’t Know

IDRC Client/Chronic Health Conditions/Tobacco Use/Drug Use/Target or Special Population

IDRC Client

Driver’s License: Populated from DASIE

Chronic Health Conditions (Check all that apply)

Asthma

Cardiovascular Disease

Chronic Obstructive Pulmonary Disease

Diabetes

Hepatitis C

Other

Tobacco Use

Does client currently use any tobacco products? (not including nicotine replacement)

Yes No

Tobacco Products used:

Cigarettes

Cigar

Pipe

Chewing Tobacco

Number of cigarettes smoked per day:

(Indicate number of cigarettes – NOT number of packs, 1 pack= 20cigarettes; 0=none)

_____ Cigarettes

Primary Drug Problem:

Drug Name:

Alcohol

Alprazolam (Xanax)

Amphetamine Barbituates

Benzodiazepine

Buprenorphine (non-prescription)

Chlordiazepoxide (Librium)

Clorazepate (Tranxene)

Cocaine - Powder

Codeine

Crack

Diazepam (Valium)

Flurazepam (Dalmane)

GHB

Hallucinogens - LSD

Hallucinogens - PCP

Heroin

Hydrocodone (Vicodin)

Hydromorphone (Dilaudid)

Inhalants

Ketamine, Special K

Lorazepam (Ativan)

Marijuana/Hashish

MDMA (MOLLY), Ecstasy

Meperidine (Demerol)

Methadone (non-prescription)

Methamphetamines

Methylphenidate (Ritalin)

Opiate - Other

Oxycodone (Oxycontin)

Pentazocine (Talwin)

Propoxyphene (Darvon)

Rohypnol (Roche, Rope, Roach)

Synthetic cannabinoids (Synthetic Marijuana, K2, Spice, Bath Salts)

Tramadol (Ultram)

Other

Frequency of Use (Primary Drug):

1. No use past month

2. Less than weekly

3. 1 to 2 times per week

4. 3 to 6 times per week

5. Daily

Age at first use for Primary: _______ years-old

Route of Administration (Primary Drug):

1. Oral

2. Inhalation/Sniffing

3. Smoking

4. Intramuscular/sub-cutaneous

5. Intravenous

Secondary Drug Problem:

Drug Name: _________________________________

(Choose from Drug List under Primary Drug)

Frequency of Use (Secondary Drug):

1. No use past month

2. Less than weekly

3. 1 to 2 times per week

4. 3 to 6 times per week

5. Daily

6. N/A

Age at first use for Secondary: ______ years-old

Route of Administration (Secondary Drug):

1. Oral

2. Inhalation/Sniffing

3. Smoking

4. Intramuscular/sub-cutaneous

5. Intravenous

6. N/A

Tertiary Drug Problem:

Drug Name: _____________________________________

(Choose from Drug List under Primary Drug)

Frequency of Use (Tertiary Drug):

1. No use past month

2. Less than weekly

3. 1 to 2 times per week

4. 3 to 6 times per week

5. Daily

6. N/A

Age at first use for Tertiary: _________ years-old

Route of Administration of Tertiary Drug):

1. Oral

2. Inhalation/Sniffing

3. Smoking

4. Intramuscular/sub-cutaneous

5. Intravenous

6. N/A

DSM IV Diagnosis (if Known)

1. ___________

2. ___________

Target/Special Population (check all that apply)

None

IV Drug User

Physical Disability

Deaf/Hard of Hearing

HIV/AIDS

Developmental Disability

DWI/DUI (Auto, Boater etc.)

Compulsive Gambling

Blind and Visually Impaired

CP&P/CWP/CPSAI

Mental Illness/Co-occurring Disorder

Controlled Environment/Treatment History/

Wait for Treatment

Controlled Environment

In the past 30 days, has client lived in a 24-hour controlled environment

such as Prison, Jail, Residential Drug Treatment Program,? (If client has

lived more than one controlled environment, select 2 choices)

1. No

2. Jail

3. Alcohol/Drug Treatment

4. Medical Treatment

5. Psychiatric Treatment

6. Other

In the past 30 days, all together how many days did client live in a controlled environment? (enter number of days 0 thru 30): ______ days

In the past 30 days, how many days has the client been treated as an

outpatient for alcohol or drug problems?

(enter number of days 0 thru 30) : ____ days

In the past 30 days, has the client been treated in an

emergency room for alcohol/drug problems?

1. No

2. Yes

Number of past alcohol and drug treatment episodes: ___

Naloxone

Have you overdosed from opioid use in the past

30 days Yes No

Life Time Yes No

Was naloxone administered in the past

30 days Yes No

Life Time Yes No

Who administered the Naloxone? 30 Days Life Time

Family Member Yes No Yes No

Medical Personal Yes No Yes No

Police Yes No Yes No

Friend Yes No Yes No

Other ________________________ Yes No Yes No

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Wait for Treatment

Enter total number of days between the client’s first contact and first

Treatment day at your agency: ________ days

Health Insurance / Funding Source (check all that apply)

Health Insurance

Medicaid

Medicare

NJ Family Care

VA/Champus

Insurance paid by client or client’s employer

Other Coverage (e.g. Worker’s Compensation)

Uninsured

Is Client in a managed care plan like an HMO or Provider Network, PPO etc.? No Yes Don’t Know

Funding Source

(When you select type of funding source, according to DASIE Initiative Eligibility the information will be shown under drop-down)

DAS Fee For Service Contract

DAS Slot Contract

Other Publicly Funded Payer (Non-DAS)

County Funding

Other Payer (Non-DAS)

Other Funding Source

SBIRT Initiative

Gambling Questions

1. Have you often spent a lot of time thinking about past gambling experience or planning future gambling ventures or bets?

1. No

2. Yes

2. Have you ever lied to family members, friends or others about how often you gamble or how much money you lost gambling?

1. No

2. Yes

3. After losing at gambling, do you try to return as quickly as possible to win back your losses

1. No

2. Yes

………… End of Admission …

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