*INVOLVED IN CHILD WELFARE: ___ Page 6A - 10 0 No 1 Yes 3 N/A – – – *RESIDENTIAL STATUS: 01 - Independent Living-alone 10 Hospital – 02 - Independent Living-with Relatives 11 - Nursing Home 03 - Independent Living Non-Relatives 12 - Supported Housing –with 04 - Dependent Living-with Relatives 13 - Correctional Facility Page 6A - 10 05 - Dependent Living-with Non-Relatives 14 - DJJ Facility 06 - Assisted Living Facility (ALF) 15 Crisis Residence – 07 - Foster Care/Home 16 Children Residential Treatment Facility – 08 - Group Home 17 Limited Mental Health Licensed ALF – 09 Homeless 99 - Not Available or Unknown – *MARITAL STATUS: 1 Single 5 - Separated – Page 6A - 11 2 Married 6 - Unreported – 3 Widowed 7 - Registered Domestic Partner – 4 Divorced 8 - Legally Separated – *SUBSTANCE PROBLEM *** (New drug list)*** Primary: Page 6A - 11 Secondary: Tertiary: *Frequency of use (Month prior to evaluation) Primary: ___ 1 - No past month use 4 - 3 to 6 times per week Page 6A - 13 Secondary: ___ 2 - 1 to 3 times in past month 5 - Daily Tertiary: ___ 3 - 1 to 2 times per week *USUAL ROUTE OF ADMINISTRATION Primary: 1 Oral 4 Injection – – Page 6A - 14 Secondary: 2 Smoking 5 Other – – Tertiary: 3 Inhalation – *AGE OF FIRST DRUG OR ALCOHOL USE Primary: Page 6A - 14 Secondary: Tertiary: *CHILD INVOLVED IN PREVENTION: ___ Page 6A - 15 0 No, 1 Yes – –
*INVOLVED IN CHILD WELFARE: ___ 0 – No 1 – Yes 3 – N/A Page 6A - 10 *RESIDENTIAL STATUS: 01 - Independent Living-alone 10 – Hospital 02 - Independent Living-with Relatives 11 - Nursing Home 03 - Independent Living –with Non-Relatives 12 - Supported Housing 04 - Dependent Living-with Relatives 13 - Correctional Facility 05 - Dependent Living-with Non-Relatives 14 - DJJ Facility 06 - Assisted Living Facility (ALF) 15 – Crisis Residence 07 - Foster Care/Home 16 – Children Residential Treatment Facility 08 - Group Home 17 – Limited Mental Health Licensed ALF 09 – Homeless 99 - Not Available or Unknown Page 6A - 10 *MARITAL STATUS: 1 – Single 5 - Separated 2 – Married 6 - Unreported 3 – Widowed 7 - Registered Domestic Partner 4 – Divorced 8 - Legally Separated Page 6A - 11 *SUBSTANCE PROBLEM *** (New drug list)*** Primary: Secondary: Tertiary: Page 6A - 11 *Frequency of use (Month prior to evaluation) Primary: ___ 1 - No past month use 4 - 3 to 6 times per week Secondary: ___ 2 - 1 to 3 times in past month 5 - Daily Tertiary: ___ 3 - 1 to 2 times per week Page 6A - 13 *USUAL ROUTE OF ADMINISTRATION Primary: 1 – Oral 4 – Injection Secondary: 2 – Smoking 5 – Other Tertiary: 3 – Inhalation Page 6A - 14 *AGE OF FIRST DRUG OR ALCOHOL USE Primary: Secondary: Tertiary: Page 6A - 14 *CHILD INVOLVED IN PREVENTION: ___ 0 – No, 1 – Yes Page 6A - 15
Form%20OUTC%20Immediate%20Discharge.docx