Using Tobacco Product: __ *CHILD INVOLVED IN PREVENTION: ___ Page 6B -13 0 No, 1 Yes – – BIRTH OUTCOME: ___ ___ 1 Live birth (drug present) 5 Pregnancy terminated – – 2 Live birth (drug not present) 6 Not yet ivered (transfers only) Page 6B 14 – – – 3 Still birth 7 Unknown Birth Outcome – – 4 - Miscarrige 8 N/A (non-pregnant only) – *friends use: Page 6B 14 – 0 - No 1 - Yes 3 Unknown – *Mother drug free: Page 6B 14 – 0 - No 1 - Yes 3 Unknown 4 N/A (non-pregnant only) – – Page 6B 14 *arrest (0-9): – *DISCHARGE REASON: 1 - Completed Episode of Care no substance abuse – 2 - Completed Episode of Care some substance use (some impairment) – 6 - Non-compliant with agency’s rules 7 - Left before completing treatment (involuntary) 8 - Incarcerated 9 Died – Page 6B 14 10 Completed Non-TX services (TASC/Interv./Prev.) – – 11 Did not complete Non-TX services (TASC/Interv./Prev.) – 13 - Referred outside of agency episode of care completed – 14 - Referred outside of agency episode of care not completed – 15 - Left before completing treatment (voluntary) 16 Administrative Discharge (Agency initiated) – 17 Agency Closed with no Referral – 99 Administrative Discharge (No Services Provided SAMH generated only) – – * status at discharge 10 - Active military, overseas Not in Work Force: 20 - Active military, 81 - Homemaker 30 - Full Time 82 Student – 83 Retired Page 6B 17 – – 31 Unpaid Family Worker – 40 - Part Time 84 - Disabled 50 - Leave of Absence 85 Inmate (Jail, Prison, Psych. Institution, etc.) – 60 Retired 86 Not Authorized to work – – 70 - Terminated (unemployed) Page 6B 17 – *future use:
Using Tobacco Product: __ *CHILD INVOLVED IN PREVENTION: ___ 0 – No, 1 – Yes Page 6B -13 BIRTH OUTCOME: ___ ___ 1 – Live birth (drug present) 5 – Pregnancy terminated 2 – Live birth (drug not present) 6 – Not yet ivered (transfers only) 3 – Still birth 7 – Unknown Birth Outcome 4 - Miscarrige 8 – N/A (non-pregnant only) Page 6B – 14 *friends use: 0 - No 1 - Yes 3 – Unknown Page 6B – 14 *Mother drug free: 0 - No 1 - Yes 3 – Unknown 4 – N/A (non-pregnant only) Page 6B – 14 *arrest (0-9): Page 6B – 14 *DISCHARGE REASON: 1 - Completed Episode of Care – no substance abuse 2 - Completed Episode of Care – some substance use (some impairment) 6 - Non-compliant with agency’s rules 7 - Left before completing treatment (involuntary) 8 - Incarcerated 9 – Died 10 – Completed Non-TX services (TASC/Interv./Prev.) 11 – Did not complete Non-TX services (TASC/Interv./Prev.) 13 - Referred outside of agency – episode of care completed 14 - Referred outside of agency – episode of care not completed 15 - Left before completing treatment (voluntary) 16 – Administrative Discharge (Agency initiated) 17 – Agency Closed with no Referral 99 – Administrative Discharge (No Services Provided – SAMH generated only) Page 6B – 14 * status at discharge 10 - Active military, overseas Not in Work Force: 20 - Active military, 81 - Homemaker 30 - Full Time 82 – Student 31 – Unpaid Family Worker 83 – Retired 40 - Part Time 84 - Disabled 50 - Leave of Absence 85 – Inmate (Jail, Prison, Psych. Institution, etc.) 60 – Retired 86 – Not Authorized to work 70 - Terminated (unemployed) Page 6B – 17 *future use: Page 6B – 17
Form%20OUTC%20Discharge.docx