Special Project Enrollment Form

Facility:SELECT ONEARCACATAWBA VALLEY MEDICAL CENTERCRISIS RECOVERY CENTERDAVIS HOSPITALFRYE REGIONALGASTON MEMORIALGRACE HOSPITALKINGS MOUNTAINPHOENIX RECOVERY CENTER-GASTONIAPHOENIX RECOVERY CENTER-SHELBYSYNERGY RECOVERY CENTERJAIL / Service Provided:SELECT ONEH0010 - NON-HOSPITAL MEDICAL DETOXH2036 - SA RESIDENTIAL(MED. MONITORED)S9487 - FACILITY BASED CRISISYP485 - NON MEDICAID FACILITY BASED CRISIS (ARCA)YP780 - GROUP LIVING HIGHYP820 - ALL HOSPITAL INPATIENT (NOT 3-WAY)YP821 - 3-WAY CONTRACT / Funding Source: SELECT ONEMEDICAIDSTATE BENEFIT PLAN
Inpatient Project Type: / ☐Substance Abuse / ☐Mental Health / Facility Record #
Insurance: / ☐None / ☐Private Insurance / ☐Medicaid #:
Admission Date: / Primary Care Physician:
Patients Name (First, MI, Last):
Maiden Name (Female): / Marital Status:SELECT ONEAnnulledSingle(Never Married)MarriedDomestic PartnersSeparatedDivorcedWidowed
SSN: / Patient DOB:
Gender: / ☐M ☐F / Pregnant: / ☐Y ☐N
Consumers Street Address:
County of Residence: / Phone Number:
Emergency Contact & Phone: / Guardian:
Primary Language: / SELECT ONEEnglishSign LanguageFrenchSpanishOtherNone / Proficient in English: / ☐Y ☐N
Race: / SELECT ONEBlack/Afric. Amer.White/Anglo/Cauc.Amer.Ind/Native AmericanAlaska NativeAsianPacific IslanderMultiracialOther / Ethnicity: / SELECT ONEHispanic, Mexican AmericanHispanic, Puerto RicanHispanic, CubanHispanic, OtherNot Hispanic Origin
Employment Status: / ☐FULL TIME ☐PART TIME ☐UNEMPLOYED / Living Arrangement: / SELECT ONE01- Private residence02- Other independent03- Homeless04- Correctional Facility05- Institution06- Residential facility07- Foster family08- Nursing home00- Other
Referral Source: / SELECT ONE01- Self or no referral10- Family or Friends21- Other OP and residential non-state facility22- State Facility23- Psychiatric service, General Hospital32- Non-residential tx/habilitation program41- Private Phisician44- Nursing home board and care46-Veteran's Administrtion48- Other health care60- Community Agency71- Court, corrections, prisons80- Schools99- Other / Veteran: / ☐Y ☐N
Highest Grade Completed: / Special Accommodations: / SELECT ONEWhellchair/Mobility NeedsSign Language InterpreterDeaf/Hearing ImpairedIntellectual DisabilityChildcareVisually ImpairedPhysical DisabilityFrail SeniorForeign Language Interpreter
1)Consumer’s Potential Risk to Self ☐NONE ☐MILD ☐MODERATE ☐SEVERE
2)Consumer’s Potential Risk to Others ☐NONE ☐MILD ☐MODERATE ☐SEVERE
3)Instability of Care Provider Supervision☐NONE ☐MILD ☐MODERATE ☐SEVERE ☐NOT SCREENED
4)Safety Issues in Living Arrangement ☐NONE ☐MILD ☐MODERATE ☐SEVERE ☐NOT SCREENED
5)Aggression of Self-Injurious Behaviors ☐NONE ☐MILD ☐MODERATE ☐SEVERE ☐NOT SCREENED
DSM-5 Diagnosis Code(s) (ICD-10):
Is consumer in need of Detox? / ☐Y ☐N ☐N/A / Withdrawal
Symptoms: / SELECT ONEAgitationsNausea and VomitingSweatsSeizuresTremors / SELECT ONEAgitationsNausea and VomitingSweatsSeizuresTremors / SELECT ONEAgitationsNausea and VomitingSweatsSeizuresTremors
IF YOU HAVE ENTERED A SUBSTANCE USE DISORDER(S) / DIAGNOSIS ABOVE YOU MUST ENTER THE SUBSTANCE USE INFORMATION BELOW ON EACH SUBSTANCE USE DISORDER
Drug(s) / SELECT ONE01- Alcohol02- Cocaine/Crack03-Marijuana/Hashish04-Heroin05-Non-Prescription Methadone06- Other Opiates and Synthetics07-PCP08-Other Hallucinogens09- Methamphetamine10-Other Amphetamines11- Other Stimulants12- Benzodiazepine13- Other Tranquilizers14-Barbiturates15- Other Sedatives and Hypnotics16- Inhalants17- Over the Counter Drugs18- Other / SELECT ONE01- Alcohol02- Cocaine/Crack03- Marijuana/Hashish04- Heroin05- Non-Prescription Methadone06- Opiates07- PCP08- Other Hallucinogens09- Methamphetamines10- Other Amphetamines11- Other Stimulants12- Benzodiazepines13- Other Tranquilizers14- Barbiturates15- Other Sedatives & Hypnotics16- Inhalants17- Over The Counter Drugs18- Other / SELECT ONE01- Alcohol02- Cocaine/Crack03- Marijuana/Hashish04- Heroin05- Non Prescription Methadone06- Other Opiates & Synthetics07- PCP08- Other Hallucinogens09- Methamphetamines10- Other Amphetamines11- Other Stimulants12- Benzodiazepines13- Other Tranquilizers14- Barbiturates15- Other Sedatives & Hypnotics16- Inhalants17- Over The Counter Drugs18- Other
Frequency of Use / SELECT ONE0- Not used in past month1- Used one to three times in past month2- Used one to two times in past week3- Used three to six times in past week4- Used daily in past week / SELECT ONE0- Not usee in past month1- used one to three times in past month2- used one to two times in past week3- used three to six times in past week / SELECT ONE0- not used in past month1- used one to three times in past month2- used one to two times in past week3- used three to six times in past week4- used daily in past week
Age of First Use (number)
Route / SELECT ONEOralSmokingInhalationInjectionOther / SELECT ONEOralSmokingInhalationInjectionOther / SELECT ONEOralSmokingInhalationInjectionOther
Target Population: / ☐AMI / MENTAL HEALTH / ☐ASTER/SUBSTANCE USE / ☐ADSN/DEVELOPMENTAL DIS.
Presenting Problem:
Name of Person Completing this Form:
Date: