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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                              Asian                  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
   No Treatment Recommended                               Not Behaviorally Handicapped                             ICD 9
   Not Applicable (MH Only)                               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                              Nursing Facility                                         Sexual Abuse Victim
    < 1st Grade                 High School Diploma
                                                          License MR Facility                                      Domestic Violence Victim/Witness
    1st Grade                   /GED                      State MH/MR Institution                                  Child of Alcohol/Drug Abuser
    2nd Grade                   Some College
                                                          Hospital                                                 HIV/AIDS
    3rd Grade                   2 Yr. College/
                                                          Correctional Facility                                    Suicidal
    4th Grade                   Assoc. Degree             Other                                                    Language barriers/English Second Language
    5th Grade                   4 Yr. College/
                                                          Unknown                                                  Hepatitis C
    6th Grade                   Assoc. Degree
                                                                                                                   Transgender
    7th Grade                   Masters/Doctorate/                                                                 Client Custody of (or placed by) ODJFS/Children’s Service
    8th Grade                   Other Profession
    9th Grade                   Technical School
    10th Grade                  Unknown
    11th Grade


                                                                                                                                          Revised 5/18/2010
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              Unknown
PCP                                                   Barbiturates
   No Drug of Choice
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



Number of Arrests in the
                                                      Primary Reimbursement                            Frequency of attendance at self-help programs
Past 30 Days                                             Self-Pay                                      in the 30 days prior to admission?
                                                         Blue Cross/Blue Shield                           No attendance in the past month
                                                         Medicare                                         1-3 times in the past month
                                                         Medicaid                                         4-7 times in the past month
                                                         Other Government Payments                        8-15 times in the past month
                                                         Worker’s Compensation                            16-30 times in the past month
                                                         Other Health Insurance Companies                 Some attendance in the past month, but frequency unknown
                                                         No Charge                                        Unknown
                                                         Other Payment Source
                                                                                                       Paying Board/Resident Board of Client



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
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 5/18/2010

				
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