ADMISSION/DISCHARGE COMBINATION FORM FY2007
1.
Client ID __ __ __ __ __ __ __ __ __ __
2.
Name
__________________________________________
3.
Birth Date __ __ / __
__ / __ __
Next two fields are
optional (4 & 5)
4.
SSN __ __ __ -
__ __ - __ __ __ __
5.
Medicaid ID __ __ __ __ __ __ __ __ __ __
6.
Admission Date __ __ /
__ __ / __ __
7.
Discharge Date __ __ /
__ __ / __ __
8.
Facility Code ____
9.
Type of Program __ __
01=Youth 02=Women (Pregnant or
Parenting)
03=Women (in Women & Children)
04=Women (in Women & Children)
99=General
10. ASAM Level __ __ - __
11. Funding
Code ____
A=Ryan White
B=State
Supervision
C=CCJJ/RSAT/Men’s
CATS
D=CIAO
E=Juvenile
Drug Court
F=FDDC
H=CJS
I=ZAPP
J=Going
Home/Re-Entry
K=Women’s
Reach In
L=DORA
M=CORA
12. Pregnant
at Admission ___
1=Yes,
2=No, 3=Unknown for females, 4=Not appropriate (Males)
13. Children Under 18 __ __
0-20, 99=Unknown
14. Drug/Alcohol Use/Problems at Admission
Type
Primary __ __
(See Codes on Back)
15. Sample Area
#1 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Sample
Area # 2 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
CODES FY2006
DRUG TYPES |
|||
|
|
GROUP LISTING |
|
NUMERIC LISTING |
|
|
|
|
|
|
00 |
None |
00 |
None |
|
04 |
Alcohol |
01 |
Heroin |
|
09 |
Marijuana/Hashish |
02 |
Non-Rx Methadone |
|
|
|
03 |
Other Opiates |
|
08 |
Cocaine, Crack |
04 |
Alcohol |
|
23 |
Methamphetamines |
05 |
Barbiturates |
|
07 |
Other Amphetamines |
06 |
Other Sedatives/Hypnotics |
|
32 |
Methylphenidate (Ritalin) |
07 |
Other Amphetamines |
|
24 |
Other Stimulants |
08 |
Cocaine, Crack |
|
|
|
09 |
Marijuana/Hashish |
|
01 |
Heroin |
10 |
Hallucinogens |
|
30 |
Oxycodone (Oxycontin,
Percocet) |
11 |
Inhalants |
|
36 |
Hydrocodone (Vicodin,
Lortab) |
12 |
Over-the-Counter |
|
37 |
Morphine |
13 |
Other Tranquilizers |
|
02 |
Non-Rx Methadone |
14 |
Other |
|
03 |
Other Opiates |
21 |
PCP |
|
|
|
23 |
Methamphetamines |
|
31 |
LSD |
24 |
Other Stimulants |
|
10 |
Other Hallucinogens |
25 |
Benzodiazepine |
|
|
|
30 |
Oxycodone (Oxycontin,
Percocet) |
|
34 |
Diazapam (Valium) |
31 |
LSD |
|
33 |
Alprazolam (Xanax) |
32 |
Methylphenidate (Ritalin) |
|
35 |
Lorazepam (Ativan) |
33 |
Alprazolam (Xanax) |
|
42 |
Clonazepam (Klonipin,
Rivotril) |
34 |
Diazepam (Valium) |
|
39 |
Rohypnol |
35 |
Lorazepam (Ativan) |
|
25 |
Other Benzodiazepines |
36 |
Hydrocodone (Vicodin,
Lortab) |
|
|
|
37 |
Morphine |
|
05 |
Barbiturates |
38 |
MDMA (Ecstasy) |
|
13 |
Other Tranquilizers |
39 |
Rohypnol |
|
06 |
Other Sedatives/Hypnotics |
40 |
GHB/GBL |
|
|
|
41 |
Ketamine (Special K) |
|
21 |
PCP |
42 |
Clonazepam (Klonipin,
Rivotril) |
|
38 |
MDMA (Ecstacy) |
|
|
|
40 |
GHB/GBL |
|
|
|
41 |
Ketamine (Special K) |
|
|
|
|
|
|
|
|
11 |
Inhalants |
|
|
|
12 |
Over-the-Counter |
|
|
|
14 |
Other |
|
|