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Ohio Behavioral Health
Admission Form
Unique Provider Number: Provider Episode Number:
First Name: Last Name:
Date of First Contact: Admission Date:
Unique Client Id: Date of Birth (mm/dd/yyyy):
Race: Alaska Native American Indian Gender: Male Female Unknown
Black/African-American Native Hawaiian/Other Pacific Islander Ethnicity: Cuban Mexican
White Other Single Race Puerto Rican Other Specific Hispanic
Two or More Races Unknown Not of Hispanic Origin Unknown
Level of care Education Enrollment Prior AOD treatment episodes with Any Agency
Pre-treatment K – 12th Grade 0 Previous Episodes
Non-intensive Outpatient GED Classes 1 Previous Episodes
Intensive Outpatient Vocational/Job Training 2 Previous Episodes
Day Treatment College 3 Previous Episodes
Non-Medical Community Residential Other School; Adult Basic Ed., Literacy 4 Previous Episodes
Medical Community Residential Not Enrolled 5 or More Previous Episodes
Ambulatory Detoxification Unknown 6 Unknown
Sub-Acute Detoxification Education Type (MH Only, K-12th Enrollment) Diagnosis type
Acute Detoxification Not Currently Enrolled as Student DSM-IV-TR
Not Applicable (MH Only) Non-Severe Behavioral Handicapped ICD 9
Severe Behavioral Handicapped
Consistent with assessment (AOD Only)? Employment Status Mental Health History (AOD Only)
Yes No If no, select reason below. Full Time Select if MH problem in addition to AOD problem
Agency Financial Constraints Part Time
Appropriate LOC not available Sheltered
Opioid Replacement Therapy
Undue Client Hardship No
Unemployed but Actively Looking for Work
Other Specify: _________________ Yes
Homemaker
Referred by Unknown
Student
Individual (includes self-referral/family/friend) Volunteer Worker
AOD Care Provider Retired Number of Children in Household Under 18
Mental Health Provider Disabled Primary Diagnosis Code
Other Health Care Provider Inmate in Jail/Prison/Corrections
School Engaged in Residential/Hospitalization
Employer/EAP Other not in Labor Force
Child Welfare Agency (i.e. CDJFS, CSBS) Unknown Secondary Diagnosis Code
Other Community Referral
Courts/Other Criminal Justice
Unknown Primary Source of Income/Support
Mental Health Only Wages/Salary Income Tertiary Diagnosis Code
Prison Family/Relative
Forensic Public Assistance
Jail Retirement/Pension
Ohio Families and children first council Disability Quaternary Diagnosis Code
TASC Other
Courts/CJ Felony Unknown
Courts/CJ Municipal None
Courts/CJ Juvenile
Marital status Living arrangements_________________ Special Populations (Select all that apply)_______
Single/Never Married Independent Living (Own Home) Severely Mentally Disabled
Married/Living Together as Married Homeless Alcohol/Other Drug Abuse
Divorced Other’s Home Forensic Legal Status
Widowed Residential Care Mental Retardation/Developmentally Disabled
Separated Respite Care Deaf/Hearing Impaired
Unknown Foster Care Blind/Sight Impaired
Crisis Care Physically Disabled
Temporary Housing Speech Impaired
Community Residence Physical Abuse Victim
Educational Level Completed
Revised 7/21/2009
< 1st Grade 12th Grade Nursing Facility Sexual Abuse Victim
1st Grade High School Diploma License MR Facility Domestic Violence Victim/Witness
2nd Grade /GED State MH/MR Institution Child of Alcohol/Drug Abuser
3rd Grade Some College Hospital HIV/AIDS
4th Grade 2 Yr. College/ Correctional Facility Suicidal
5th Grade Assoc. Degree Other Language barriers/English Second Language
6th Grade 4 Yr. College/ Unknown Hepatitis C
7th Grade Assoc. Degree Transgender
8th Grade Masters/Doctorate/ Client Custody of (or placed by) ODJFS/Children’s Service
9th Grade Other Profession
10th Grade Technical School
11th Grade Unknown
Additional Client Information (Female Only)
Stage of pregnancy (if Client is Pregnant) Military status (Check all that Apply)
Child Birth within the last 5 years? 1st Trimester None Afghanistan Veteran
Yes No_______________________________ 2nd Trimester Discharged Iraqi Veteran
3rd Trimester Active duty
Total Number of Births (live and still) Unknown Disabled Veteran
Available Drug Choices
Alcohol Other Hallucinogens Other Non-Barbiturate Sedatives or Hypnotics
Cocaine/Crack Methamphetamines Inhalants
Marijuana/Hashish Other Amphetamines Over-the-Counter Medications
Heroin Other Stimulants Nicotine
Non-prescription methadone Benzodiazepines Other Medications
Other Opiates and Synthetics Other Non-Barbiturate Tranquilizers None
PCP Barbiturates Unknown
Primary Drug of Choice Frequency of Use Route of Administration
(Select from above) No Use in the last Past Month Oral
1 – 3 Times in the Past Month Smoking
1 – 2 Time in the Past Week Inhalation
Injection
(Age of first 3 – 6 Time in the Past Week
Other
intoxication when Daily
Age of First Use Unknown
Alcohol drug choice) Unknown
Secondary Drug of Choice Frequency of Use Route of Administration
(Select from above) No Use in the last Past Month Oral
1 – 3 Times in the Past Month Smoking
1 – 2 Time in the Past Week Inhalation
(Age of first 3 – 6 Time in the Past Week Injection
intoxication when Daily Other
Age of First Use Alcohol drug choice) Unknown Unknown
Tertiary Drug of Choice Frequency of Use Route of Administration
(Select from above) No Use in the last Past Month Oral
1 – 3 Times in the Past Month Smoking
1 – 2 Time in the Past Week Inhalation
(Age of first 3 – 6 Time in the Past Week Injection
intoxication when Daily Other
Age of First Use Alcohol drug choice) Unknown Unknown
Participation in self-help groups, support
Number of Arrests in the
Primary Reimbursement group, etc, (e.g. AA, NA, etc) in
Past 30 Days Self-Pay the past 30 days? Yes No
Blue Cross/Blue Shield Paying Board/Resident Board of Client
Medicare
Medicaid
Other Government Payments
Worker’s Compensation
Other Health Insurance Companies
No Charge
Other Payment Source
Access and Retention Measures Family Reunification Women’s Program
STAR-SI Participant? Yes / No HB484 Participant? Yes / No Involved in a Women’s Program? Yes / No
Client Group: Not Applicable Were children removed from home? Yes / No At time of Admission was program at or above 90%? Yes / No
408 Program Board Funded Is there a waiting list? Yes / No
Medicaid/Indigent Unknown Was interim services provider due to client being on waiting
Revised 7/21/2009
1st Date of Service: list? Yes / No
TASC
Type Of Client Parolee
Adult TASC Unknown Unknown Federal Parolee
Juvenile TASC ODRC Parolee Unknown
DYS DYS Parolee
Revised 7/21/2009
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