STATE OF SUBSTANCE ABUSE & MENTAL HEALTH SUBSTANCE ABUSE DISCHARGE FORM (* Mandatory Fields) (Reference: Chapter 6b, DCF Pam 155-2) Client’s Name: *CLIENT SSN: - - Page 6B - 3 The SSN must be 9 digits without dashes. It cannot start with 000 or 999. If unavailable use Pseudo-social. Instructions in SAMH Pamphlet *CONTRACTOR IDENTIFIER: - Page 6B 3 – Federal Tax Identification number ex. 59-1234567. Page 6B 3 – OF EVALUATION: 3 Discharge – *PURPOSE Page 6B 3 – DATE: _ _ / _ _ / _ _ _ _ *EVALUATION Page 6B 3 – *Provider ID: __ __ -- __ __ __ __ __ __ __ Page 6B 3 – *STAFF ID: __ __ - Page 6B 4 – *SITE IDENTIFIER: ___ ___ Page 6B 4 – *CLIENT ID: : Page 6B 4 – *: ___ ___ Page 6B 5 – *SA PRIMARY DIAGONSIS: . Page 6B 5 – MH DIAGONSIS: . *HIGHEST EDUCATION: 20 - No Schooling 29 - 1 or more year College, No Degree 21 - Nursery Schooling to 4th Grade 30 - Degree (AA, AS, etc.) Associate’s 22 - 5th to 6th Grade 31 - Degree (BA, BS, AB, etc.) Bachelor’s 23 - 7th to 8th Grade 32 - Degree (MS, MA, MSW, etc.) Page 6B 5 Master’s – 24 - 9th Grade 33 - Prof. Degree (MD, DDS, JD, etc.) 25 - 10th Grade 34 - Doc. Degree (PhD, EDD, etc.) 26 - 11th Grade 35 - Special School 27 - 12th Grade, No Diploma 36 - Vocational School 28 - High School Graduate, Diploma or Degree
STATE OF SUBSTANCE ABUSE & MENTAL HEALTH SUBSTANCE ABUSE DISCHARGE FORM (* Mandatory Fields) (Reference: Chapter 6b, DCF Pam 155-2) Client’s Name: *CLIENT SSN: - - The SSN must be 9 digits without dashes. It cannot start with 000 or 999. If unavailable use Pseudo-social. Instructions in SAMH Pamphlet Page 6B - 3 *CONTRACTOR IDENTIFIER: - Federal Tax Identification number ex. 59-1234567. Page 6B – 3 *PURPOSE OF EVALUATION: 3 – Discharge Page 6B – 3 *EVALUATION DATE: _ _ / _ _ / _ _ _ _ Page 6B – 3 *Provider ID: __ __ -- __ __ __ __ __ __ __ Page 6B – 3 *STAFF ID: __ __ - Page 6B – 3 *SITE IDENTIFIER: ___ ___ Page 6B – 4 *CLIENT ID: : Page 6B – 4 *: ___ ___ Page 6B – 4 *SA PRIMARY DIAGONSIS: . Page 6B – 5 MH DIAGONSIS: . Page 6B – 5 *HIGHEST EDUCATION: 20 - No Schooling 29 - 1 or more year College, No Degree 21 - Nursery Schooling to 4th Grade 30 - Associate’s Degree (AA, AS, etc.) 22 - 5th to 6th Grade 31 - Bachelor’s Degree (BA, BS, AB, etc.) 23 - 7th to 8th Grade 32 - Master’s Degree (MS, MA, MSW, etc.) 24 - 9th Grade 33 - Prof. Degree (MD, DDS, JD, etc.) 25 - 10th Grade 34 - Doc. Degree (PhD, EDD, etc.) 26 - 11th Grade 35 - Special School 27 - 12th Grade, No Diploma 36 - Vocational School 28 - High School Graduate, Diploma or Degree Page 6B – 5