Ohio Behavioral Health Admission Form Unique Provider Number: 01537 First Name: Date of First Contact: Unique

ue Client Id:
(First 3 Letters of Last Name and 6-Digit Date of Birth)

Chart Number: Last Name: Admission Date: Gender:

Male Female Cuban Hispanic Mexican Unknown Other Specific Hispanic Unknown

Race:
Black/African-American White Two or More Races Native Hawaiian/Other Pacific Islander Other Single Race Alaska Native Unknown American Indian

Ethnicity:
Puerto Rican Not of Hispanic Origin

Level of care
Pre-treatment (A1) Non-intensive Outpatient (B1) Intensive Outpatient (B2) Day Treatment (B3) Non-Medical Community Residential (C1) Medical Community Residential (C2) Ambulatory Detoxification (D1) Sub-Acute Detoxification (D3) Acute Detoxification (E1) Not Applicable (MH Only) (NA) Consistent with assessment (AOD Only)? Yes No If no, select reason below. Agency Financial Constraints Appropriate LOC not available Undue Client Hardship Other Specify: _________________

Education Enrollment
K 12th Grade (A) GED Classes (B) Vocational/Job Training (C) College (D) Other School; Adult Basic Ed., Literacy (E) Not Enrolled (F) Unknown (U) Education Type (MH Only, K-12th Enrollment) Not Currently Enrolled as Student Non-Severe Behavioral Handicapped Severe Behavioral Handicapped

Prior AOD treatment episodes (Any Agency)

0 Previous Episodes 1 Previous Episodes 2 Previous Episodes 3 Previous Episodes 4 Previous Episodes 5 or More Previous Episodes 6 Unknown

Diagnosis type
DSM-IV-TR

Employment Status
Full Time (A) Part Time (B) Sheltered(C) Unemployed but Actively Looking for Work (D) Homemaker (E) Student (F) Volunteer Worker (L) Retired (G) Disabled (H) Inmate in Jail/Prison/Corrections (I) Engaged in Residential/Hospitalization (K) Other not in Labor Force (J) Unknown (M)

Mental Health History (AOD Only)

Select if MH problem in addition to AOD problem

Opioid Replacement Therapy

No

Referred by
Individual (includes self-referral/family/friend) (A) AOD Care Provider (B) Mental Health Provider (C) Other Health Care Provider (E) School (F) Employer/EAP (G) Child Welfare Agency (i.e. CDJFS, CSBS) (H) Other Community Referral (I) Courts/Other Criminal Justice (P) Courts/CJ Felony (J) Courts/CJ Municipal (K) Courts/CJ Juvenile (M) Unknown(T) Mental Health Only Prison (O) Forensic (Q) Jail (R) Ohio Families and Children First Council (S)

Number of Children in Household Under 18

Primary Diagnosis Code

Secondary Diagnosis Code

Primary Source of Income/Support

Wages/Salary Income (A) Family/Relative (B) Public Assistance (J) Retirement/Pension (H) Disability (F) Other (C) Unknown (U) None (P)

Tertiary Diagnosis Code

Quaternary Diagnosis Code

Marital status
Single/Never Married Married/Living Together as Married Divorced Widowed Separated Unknown

Living Arrangements
Independent Living (Own Home) (A) Homeless (S) Others Home (B) Residential Care (D) Respite Care (L) Foster Care (H) Crisis Care (G) Temporary Housing (V) Community Residence (E) Nursing Facility (J) Licensed MR Facility (N) State MH/MR Institution (O) Hospital (Q) Correctional Facility (R) Other (U) Unknown (W)

Special Populations (Select all that apply)

Severely Mentally Disabled Alcohol/Other Drug Abuse Forensic Legal Status Mental Retardation/Developmentally Disabled Deaf/Hearing Impaired Blind/Sight Impaired Physically Disabled Speech Impaired Physical Abuse Victim Sexual Abuse Victim Domestic Violence Victim/Witness Child of Alcohol/Drug Abuser HIV/AIDS Suicidal Language barriers/English Second Language Hepatitis C Transgender Client Custody of (or placed by) ODJFS/Childrens Service None of the Above/General Population

Educational Level Completed

< 1st Grade (00) 1st Grade (01) 2nd Grade (02) 3rd Grade (03) 4th Grade (04) 5th Grade (05) 6th Grade (06) 7th Grade (07) 8th Grade (08) 9th Grade (09) 10th Grade (10) 11th Grade (11) 12th Grade (12) High School Diploma /GED (12) Some College (14) 2 Yr. College/ Assoc. Degree (15) 4 Yr. College/ Assoc. Degree (16) Masters/Doctorate/ Other Profession (18) Technical School (13) Unknown (26)

Revised 07/06/2011

Additional Client Information (Female Only)

Child Birth within the last 5 years? No Yes Total Number of Births (live and still) Stage of pregnancy (if Client is Pregnant) 1st Trimester 2nd Trimester 3rd Trimester Unknown

Military status (Check all that Apply)

None (N) Discharged (Y) Active duty (A) Disabled Veteran (V) Afghanistan Veteran Iraq Veteran

Participation in self-help/support groups, (AA, NA) in the past 30 days?

No Yes (If Yes Only) 23 times per week (B) 13 times in the past month (less than 1x/week) (C) 4 or more times per week (D) No attendance in past month (N) Some attendance, but frequency unknown (S) Unknown (U) About once per week (W)

(e.g. Primary Reimbursement

Self-Pay (S) Blue Cross/Blue Shield (B) Medicare (M) Medicaid (I) Other Government Payments (G) Workers Compensation (W) Other Health Insurance Companies (H) No Charge (N) Other Payment Source (O)

Number of Arrests in the Past 30 Days

Paying Board/Resident Board of Client

Mental Health & Recovery Board of Wayne & Holmes Counties Other: (specify)

Available Drug Choices

Alcohol (0201) Cocaine/Crack (0301) Marijuana/Hashish (0401) Heroin (0501) Non-prescription methadone (0601) Other Opiates and Synthetics (0701) PCP (0801)

Other Hallucinogens (0901) Methamphetamines (1001) Other Amphetamines (1101) Other Stimulants (1201) Benzodiazepines (1301) Other Non-Barbiturate Tranquilizers (1401) Barbiturates (1501)

Other Non-Barbiturate Sedatives or Hypnotics (1604) Inhalants (1701) Over-the-Counter Medications (1801) Nicotine (9999) Other Medications (2001) None (0000) Unknown (9997)

Primary Drug of Choice

(Select from above)

Frequency of Use
No Use in the last Past Month (0) 1 3 Times in the Past Month (1) 1 2 Time in the Past Week (2) 3 6 Time in the Past Week (3) Daily (4) Unknown (8)

Route of Administration
Oral (1) Smoking (2) Inhalation (3) Injection (4) Other (9) Unknown (7)

Age of First Use Secondary Drug of Choice

(Select from above)

Frequency of Use
No Use in the last Past Month (0) 1 3 Times in the Past Month (1) 1 2 Time in the Past Week (2) 3 6 Time in the Past Week (3) Daily (4) Unknown (8)

Route of Administration
Oral (1) Smoking (2) Inhalation (3) Injection (4) Other (9) Unknown (7)

Age of First Use Tertiary Drug of Choice

(Select from above)

Frequency of Use
No Use in the last Past Month (0) 1 3 Times in the Past Month (1) 1 2 Time in the Past Week (2) 3 6 Time in the Past Week (3) Daily (4) Unknown (8)

Route of Administration
Oral (1) Smoking (2) Inhalation (3) Injection (4) Other (9) Unknown (7)

Age of First Use Age of First Alcohol Intoxication Client involved with CSB?
No Yes

Client part of Amish Community? Meet criteria for Indigent Driver Fund?
Does the Client have any Substance Dependency Diagnosis? No Yes

No

Yes

No Yes (Mark Yes if meets both criteria below) Is the Client involved with Court, or likely (i.e. attorney involvement) to be soon involved with Court regarding an impaired driving or related charge? No Yes

Name of Person Completing This Form

Date Completed

Revised 07/06/2011