Drug: __ 0 No – Alcohol: __ 1 Yes – Tobacco: __ 3 - Unknown Using Tobacco Product: __ *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 Page 6C – 15 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) Page 6C – *End Date: ___ ___ / ___ ___ / ___ ___ ___ ___ 15 REFERRAL: ___ ___ 1 - Individual (Self-Referral) 14 - Other Court Order/Recognized Legal Entity 2 - Substance Abuse Care Provider 16 - SINS/FINS 3 - Mental Health Care Provider 17 - Addictions Receiving Facilities 4 - Juvenile 18 - Outreach Program Justice (JARF’s) 5 - Health Unit 19 - DCF/ADM (no longer used) 6 - School (Education) 20 - 7 - Employer/Employee 21 - Page 6C - 15 Assistance Program 22 - Physician/Doctor 8 - Other Social Service/Health/ 23 - Law Enforcement Community Ref 24 - Family Safety Foster Care 9 - TASC (Assessment Centers) 25 - Family Safety Protective Services 10 - Probation/Parole/Controlled 99 - None of the Above Release Authority 11 - DUI/DWI 12 Pretrial – 13 - Prison/Jail Page 6C – *ZIP CODE: ___ ___ ___ ___ ___ US Postal Zip code for this client’s residence 16 Page 6C - 16 PROVIDER INFORMATION: Page 6C - 16 *Veteran status ____ 0 No 1 Yes 2 Unknown – – – Page 6C - 16 *Contract Number 1 - __ __ __ __ __ Page 6C - 17 Contract Number 2 - __ __ __ __ __ Page 6C - 17 Contract Number 3 - __ __ __ __ __
Drug: __ 0 – No Alcohol: __ 1 – Yes Tobacco: __ 3 - Unknown Using Tobacco Product: __ *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) Page 6C – 15 *End Date: ___ ___ / ___ ___ / ___ ___ ___ ___ Page 6C – 15 REFERRAL: ___ ___ 1 - Individual (Self-Referral) 14 - Other Court Order/Recognized Legal Entity 2 - Substance Abuse Care Provider 16 - SINS/FINS 3 - Mental Health Care Provider 17 - Addictions Receiving Facilities 4 - Juvenile Justice (JARF’s) 18 - Outreach Program 5 - Health Unit 19 - DCF/ADM (no longer used) 6 - School (Education) 20 - 7 - Employer/Employee 21 - Assistance Program 22 - Physician/Doctor 8 - Other Social Service/Health/ 23 - Law Enforcement Community Ref 24 - Family Safety Foster Care 9 - TASC (Assessment Centers) 25 - Family Safety Protective Services 10 - Probation/Parole/Controlled 99 - None of the Above Release Authority 11 - DUI/DWI 12 – Pretrial 13 - Prison/Jail Page 6C - 15 *ZIP CODE: ___ ___ ___ ___ ___ US Postal Zip code for this client’s residence Page 6C – 16 PROVIDER INFORMATION: Page 6C - 16 *Veteran status ____ 0 – No 1 – Yes 2 – Unknown Page 6C - 16 *Contract Number 1 - __ __ __ __ __ Page 6C - 16 Contract Number 2 - __ __ __ __ __ Page 6C - 17 Contract Number 3 - __ __ __ __ __ Page 6C - 17
Form%20OUTC%20Detox.docx