SMART DISCHARGE. Client s Name: Client ID: Partial Hospitalization Clinically Managed Medium Intensity Residential Treatment
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1 SMART DISCHARGE Client s Name: Client ID: DATE OF DISCHARGE: Reason for Discharge Completed Treatment no further treatment needed Completed Treatment Plan/Referred Incomplete Client Left Before Completing Treatment Incomplete Non-Compliance-Program Rules Incomplete Treatment/Death Discharge Referral Incomplete Treatment/Transferred -OMT Opioid Maintenance Therapy Partial Hospitalization Clinically Managed Medium Intensity Residential Treatment Incomplete Treatment/Health Problems Incomplete Treatment/Incarcerated Clinically Managed Low Intensity Residential Incomplete Treatment Treatment/Referred Clinically Managed High Intensity Residential Treatment Medically Monitored Intensive Inpatient Treatment Medically Managed Intensive Inpatient Services # of times the client has attended a No attendance in the past month 8-15 times in the past month self-help program in the 30 days 1-3 times in the past month times in the past month preceding the date of admission to 4-7 times in the past month treatment services. Number of Arrests During Last 30 Days: Is Client Currently Pregnant? Living Arrangement Employment Status: Employed Full Time (35 hours or more) Employed Part Time in steady job Homemaker Full Time In Skill Development, Training or School Other, Out of Work Force Retired/Permanently Out of Work Revised 3/14/12 1
2 Primary Income Source Disability Public Assistance/TCA Retirement/Pension Self-Employment Unemployment Compensation Unknown Wages/Salary Veterans Status Education Status For grades 1-12 enter the number 13 College coursework 14 Earned College AA/Associates 15 Earned BA/BS 16 Post College/Graduate School Duty Never in combat In Combat 0-6 months ago In Combat 6-12 months ago In Combat more than 12 months ago. Explanation for Veterans Status. When asking about a client s veterans status please select from the list documented here on the form only. Revised 3/14/12 2
3 Please see attachment to complete Substance Matrix Substance Matrix Chart to be Used to Indicate Substance Use at Admission and at Discharge Substance 1=substance most used or abused 2=substance two 3=substance three Severity 0=Not a problem (discharge only) 1=Mild Problem 2=Moderate Problem 3=Severe Problem Frequency 0=No use past month 1=1-3 times past month 2=1-2 times past week 3=3-6 times per week 4=Once Daily 5=2-3 times daily 6=More than 3 times daily Route 1= Oral 2=Smoking 3=Inhalation 4=Injection 5=Other Rating Substance Severity Freq. Route Age/Use Alcohol Amphetamines - Amphetamine Amphetamines - Methamphetamine (Speed) Amphetamines - Methylenedioxymethamphetamine (MDMA,Ecstacy) Amphetamines - Other Barbiturates - Phenobarbital (Solfoton) Barbiturates - Secobarbital (Seconal) Barbiturates - Secobarbital/Amobarbital (Tuinal) Barbiturates - Other Benzodiazepines - Alprazolam (Xanax) Benzodiazepines - Chlordiazepoxide (Librium) Benzodiazepines - Clonazepam (Klonopin, Rivotril) Benzodiazepines - Clorazepate (Tranxene) Benzodiazepines - Diazepam (Valium) Benzodiazepines - Flunitrazepam (Rohypnol) Benzodiazepines - Flurazepam (Dalmane) Benzodiazepines - Lorazepam (Ativan) Benzodiazepines - Triazolam (Halcion) Benzodiazepines - Other Cocaine - Crack Cocaine - Other Diphenylhydantoin/Phenytoin (Dilantin) GHB/GBL (Gamma-Hydroxybutyrate, Gamma-Butyrolactone) Hallucinogens - LSD Hallucinogens - Other Inhalants - Aerosols Inhalants - Nitrites Inhalants - Solvents Inhalants - Other Ketamine (Special K) Marijuana/Hashish Meprobamate (Miltown) Opiates/Synthetics - Codeine Opiates/Synthetics - Heroin Opiates/Synthetics - Hydracodone (Vicodin) Opiates/Synthetics - Hydromorphone (Dilaudid) Opiates/Synthetics - Meperdine (Demoral) Opiates/Synthetics - Non-Prescription Methadone Opiates/Synthetics - Oxycodone (OxyContin, Percocet, Percodan) Opiates/Synthetics - Pentazocine (Talwin) Opiates/Synthetics - Propoxyphene Opiates/Synthetics - Tramadol (Ultram) Opiates/Synthetics - Other Over The Counter - Diphenhydramine (Benadryl) Over The Counter - Other PCP or PCP Combination Sedatives - Ethchlorvynol (Placidyl) Sedatives - Glutethimide (Doriden) Sedatives - Methaqualone (Quaaludes) Sedatives - Other Stimulants - Methylphenidate (Ritalin) Stimulants - Other Tranquilizers Other Drug Revised 3/14/12 3
4 Were Mental Health Services Received? Yes Does client currently use tobacco? Daily frequency of cigarette use: Tobacco/Nicotine Screen Have you ever used Tobacco/Nicotine products? If yes, answer the rest of the questions on this page. Otherwise, go to next page. Smoker Status ent status unknown At what age did you first use tobacco/nicotine product(s)? In the past 30 days, what tobacco/nicotine product did you use most frequently? Cigarettes In the past 30 days, how often did you use tobacco/nicotine product(s)? In the past 30 days, how many cigarettes did you smoke per week? Revised 3/14/12 4
5 DISCHARGE SPECIALFUNDING/SPECIAL PROJECTS Special Funding House Bill 1160 (HB 1160) Temporary Cash Assistance (TCA) Senate Bill 512/495/Prenatal (SB 512/495) Senate Bill 512/Post Partum (SB 512) Primary Payment Source Primary Adult Care (PAC) ADAA (State Funding) DHMH Grant ADAA Medicaid Other than Healthchoice Healthchoice (MA) Medicare Non-Managed Private Insurance Private Managed Care/HMO Out of Pocket Payment Other Public Funds Drug Court Other Additional Payment Source Primary Adult Care (PAC) ADAA (State Funding) DHMH Grant ADAA Medicaid Other than Healthchoice Healthchoice (MA) Medicare Non-Managed Private Insurance Private Managed Care/HMO Out of Pocket Payment Other Public Funds Drug Court Other Available Ancillary Services Other Ancillary Referrals To Community Mental Health Services To Detox Services To General Hospital To Self Help Programs (AA, NA) Current Educational Activities K - 12 No Yes Vocational Training: No Yes GED Program: No Yes Higher Education No Yes Current Educational Activities # of individual counseling sessions: # of urinalysis: # of group counseling sessions: # of positive urinalysis: # of family counseling sessions: # of days in detox: Revised 3/14/12 5
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