WM CalOMS Discharge Questionnaire

Unicare IDWM Diisschcharargege

Left before completion with satisfactory progress

Discharge Reason (Choose one)

Discharge Date

- -

* Specify Drug NamePPPage 1 oage 1 oage 1 of 3

Primary Substance Use Route of Admin

Substa

nce

Drug N

ame

Past

#3

D0 a

Dy

as

ys

Age U a

st

eO

First

ral Sm Io

nk

hi

ang

Inl

ja

et

ci

to in

Oton

her

None

Heroin o o o o oAlcohol o o o o oBarbiturates* o o o o oOther Sedatives or Hypnotics* o o o o oMethamphetamine o o o o oOther Amphetamines* o o o o oOther Stimulants* o o o o oCocaine / Crack o o o o oMarijuana / Hashish o o o o oPCP o o o o oOther Hallucinogens* o o o o oTranquil izers (Benzodiazepine)* o o o o oOther Tranquil izers* o o o o oNon-Prescription Methadone o o o o oOxycodone / OxyContin o o o o oOther Opiates or Synthetics* o o o o oInhalants* o o o o oOver-the-Counter* o o o o oEcstasy o o o o oOther Club Drugs* o o o o oOther* o o o o o

AOD use during past 30 days

Rev. 1.0, 1/7/2020, KC, PRC

WM Discharge

PPage 2 oage 2 of 3

AOD use during past 30 days

Unicare ID

Secondary Substance Use Route of Admin

Substa

nce

Drug N

ame

Past 3

0 Day

s

# Day

s

Age at

First

Use Oral Smokin

g

Inhalatio

n

Injection

Other

None

Heroin o o o o oAlcohol o o o o oBarbiturates* o o o o oOther Sedatives or Hypnotics* o o o o oMethamphetamine o o o o oOther Amphetamines* o o o o oOther Stimulants* o o o o oCocaine / Crack o o o o oMarijuana / Hashish o o o o oPCP o o o o oOther Hallucinogens* o o o o oTranquil izers (Benzodiazepine)* o o o o oOther Tranquil izers* o o o o oNon-Prescription Methadone o o o o oOxycodone / OxyContin o o o o oOther Opiates or Synthetics* o o o o oInhalants* o o o o oOver-the-Counter* o o o o oEcstasy o o o o oOther Club Drugs* o o o o oOther* o o o o o

* Specify Drug Name

Rev. 1.0, 1/7/2020, KC, PRC

WM Discharge

Page 3 of 3

(Ask next question only if primary, secondary drug is not alcohol)

Number of days in the past 30 days client used Alcohol? .........................................................................days

Unicare ID

(0 -30)None/Not Applicable

Were you pregnant at any time during the treatment? ......................... Yes No Not Sure

What type of disability/disabilities do you have?None Visual Hearing SpeechMobility Mental Developmentally Disabled Other Disability (not AOD)Declined to State Unable to answer

(Check all that apply)

Ever been diagnosed with a mental illness? ..................................................................... Yes No Not Sure

How many days, in the past 30 days, have you participated in any social support recovery activities (such as 12-step meetings, other self help meetings, religious/faith recovery meetings, meetings of ..........an organization other than those listed above, interactions with family members and/or friend forsupport of your recovery)?

days(0 -30)

Current living arrangements:

Homeless No stable arrangements Transitional Housing/Residential

Parents Family Friends

Sexual partner alone Sexual partner & children Children alone

Alone Board & Care

Are you currently enrolled in school?

If enrolled, how many days in the past 30 days have you missed school? ...................................................

Employment Status Employed Full time (35 hours or more) Unemployed, not in the labor force (not seeking)

Employed Part time (less than 35 hrs.) Not in the labor force (Not seeking)

Unemployed, looking for work

Yes No Declined to State Unable to answer

(0 -30)days

How many days in the past 30 days ..............................................................................................................have you had serious conflicts with your family?

How many times have you been arrested in the past 30 days? ....................................................................Unable to Answer

Declined to Answer Unable to Answerdays(0 -30)

(0 -30)days

Name of data entry staff:

Rev. 1.0, 1/7/2020, KC, PRC