Department of Human Services (DHS)
Division of Addiction Services (DAS)
Information Systems Management Unit (ISM)
NJSAMS - 1
Data Entry form on Paper
NJSAMS Administrative Module
Admission and Discharge
Press < ctrl+p > to print
(Note: Press <ctrl > key and < p > key at the same time)
Press “Back Button” from top menu bar to Main NJSAMS Homepage
(Please download and keep extra copies at all time in case of Internet Connection failure)
NJSAMS Training and Demonstration Site
http://samsdev.rutgers.edu/samstraining/mainhome.htm
NJSAMS Real-time Data System (Do not use training or demo. purposes)
https://njsams.rutgers.edu/samsmain/mainhome.htm
If you have any questions please call customer service at
Phone: 609-292-3331; 609-943-5905; 609-292-1466
Email: [email protected] or [email protected]
Updated: 06/15/2006
NJSAMS Data Entry Forms
Any questions please call (609) 292-1466, (609) 943-5905
CLIENT ADMINISTRATIVE INFORMATION
Client’s:
________________ ___________
First name
Middle name
(Admission)
Residence Code:
____________________
Last name
Phone #: (______) ______ - __________
Email: _________________________________
Social Security# -
-
-
Contact name: _________________________________
Contact Address:
_____________________________________________
Gender (M/F/Transgender/Other):
Date of birth:
/
Contact City, State, Zip
________________________________________
/
Contact Phone #: (______) ______ - __________
Date of Admission:
Date of Interview:
/
/
/
/
/
Contact Email: _________________________________
/
Length of time at current address: ______(Years) , _____ (Months)
Latino or Hispanic Origin:
1. Not of Hispanic Origin
2. Puerto Rican
3. Mexican
4. Cuban
5. Dominican
6. Other Hispanic SPECIFY: ________________
In-House Case #
*Client Type:
1. Alcohol/Drug Abuser
2. Co-Dependent/ Family (non-substance abuser)
Race: (Select up to two choices):
1. White
2. Black
3. Asian
4. Alaskan Native
5. American Indian
6. Native Hawaiian or other Pacific Islander
*Treatment Type:
1. Admission in a New Episode
2. Continuing Care within same Agency
3. Continuing Care Transfer from another Agency
*Level Of Care (LOC):
Household Income Per Year: $_________________
1. Standard/Traditional Outpatient
2. Intensive Outpatient
3. Partial Hospitalization
4. Transitional Care/ Extended Care
5. Halfway House
6. Long-Term Residential
7. Short-Term Residential (Medically Monitored)
8. Hospital-Based (acute) Residential
9. Detox-Free-Standing Residential (Sub-Acute)
10. Detox-Hospital Inpatient
11. Detox-Outpatient (Non-Methadone)
12. OPIOID Maintenance-Outpatient
13. Detox-Mehtadone Outpatient
14. Non-Traditional Program
15. OPIOID Maintenance-Intensive Outpatient
Household Size: ___________
Number of past Alcohol & Drug Treatment Episode:
Self-help Group ever participated in
1. Narcotic Anonymous
2. Alcohol Anonymous (AA)
3. None
4. Other
What is your religious preference?
1. Protestant
2. Catholic
3. Jewish
4. Islamic
5. Other…………SPECIFY:______________
6. None
8. Refused
9. Don’t Know
*Site Location: _________________________________________
*Methadone:
Is use of methadone planned as part of treatment?
1. Yes
2. No
3. Don’t Know
Is the client a Veteran 1. Yes 2. No
Is the client a Katrina evacuee 1. Yes 2. No
What is the highest grade you completed in school?
Living Arrangement at admission:
Do you have a high school diploma or GED
1.
No
2.
Yes
Are you currently enrolled in school or a job training program?
1. Not enrolled (If not enrolled answer the following if applicable..)
1.Dropped out
2.Expelled
3.Suspended
1. Homeless-Shelter
2. Homeless-Streets
3. Dependent Living/Institution
4. Independent Living
Address : _____________________________________________
City, State, Zip ________________________________________
NJSAMS Data Entry Forms
Page 1 of 9
Any questions please call (609) 292-1466, (609) 943-5905
(Admission Contd ……)
4. VA/Champus
5. Insurance paid by client or client’s employer (BCBS, Aetna etc.)
6. Other Coverage (eg. Worker’s Compensation)
7. Uninsured
4.Medical Leave
5.Home Study
6.Other
2. Enrolled Full –Time
3. Enrolled Part –Time
4. Other
Is Client in a managed care plan like HMO or Provider Network, PPO
etc.?
1. No
2. Yes
3. Don’t know
Which best describes your CURRENT employment situation?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Full-time work or military (35 hours a week or more)
Part-time (regular hours)
Part-time (not regular hours)
Student
Home Maker
Retired or Disabled
Unemployed: Actively looking for work
Unemployed: Not looking for work
Unemployed: Volunteer work
Living in an institution, like a jailor prison, hospital or overnight
treatment program
Dependent Children:
Is the client bringing dependent children into treatment?
1. No
2. Yes, If Yes, how many Children
Referral Source (Check only one – Numeric Field):
1. Self
2. Family/Friend
3. Addiction Services
31 = Addiction Treatment Program
32 = County Drug and Alcohol Coordinator
33 = South Jersey Initiative
34 = Other
4. Corrections Related Programs
41 = Municipality - Municipal Court
If “Municipal Court” is selected, enter 4-digit
municipality code :
What is your current marital status?
1. Never Married
2. Married
3. Widowed
4. Separated
5. Divorced
If not “married”: Are you currently living with a significant other?
42 = County - Family Court
43 = County - Drug Court
44 = County - Other
45 = County - Probation
46 = County - Detention Center
If any county related is selected
Enter County Code :
1. No
2. Yes
What is your Current Legal Status?
1. No Legal Problem
2. Case Pending
3. Drug Court
4. Probation
5. Parole
6. DWI License Suspension
7. Jail/Prison Inmate
8. DYFS or Family Court
9. Other
47 = STATE - NJ Department of Correction
48 = STATE – NJ State Parole Board/Parole District Office
49 = FEDERAL - US Federal Prison
50 = FEDERAL - US Federal Court
52 = Juvenile Justice Commission (JJC)
53 = Other
If other; Specify __________________
5. Intoxicated Drivers Resource Center (IDRC)
If “IDRC” is selected, enter county code of IDRC
How many times have you been arrested and charged for an offense in
the past 30 days?
County Code:
6. Mental Health
61 = Mental Health Screening Center
62 = Mental Health Provider/Clinic
63 = Hospital
65 = MICA Program
64 = Other
Pregnancy Questions
How many times in your life have you been pregnant?
times
How many of these pregnancies resulted in a live birth?
7. Medical/Health
pregnancies
71 = County or Municipal Health Department
72 = Hospital, Crisis Emergency Room
73 = Other Hospital
74 = Health Care Agency/Private Physician
75 = Other
Have you given birth to a child in the past 12 months?
1. No
2. Yes
Are you pregnant now?
1. Yes
2. No
3. Don’t know
8. Welfare/Social Services
81 = NJ Dept. of Human Services – DYFS
82 = WFNJ-Substance Abuse Initiative (SAI)
83 = Substance Abuse Research Demonstration
84 = Other
How many of your children are still living today?
children
9. Employee Assistance Program
10. Hotline
11. Other
Health Care Coverage (Check all that apply):
1. Medicaid
2. Medicare
3. NJ FamilyCare
NJSAMS Data Entry Forms
Page 2 of 9
Any questions please call (609) 292-1466, (609) 943-5905
(Admission Contd ……)
Route of Administration (Primary Drug):
1.
2.
3.
4.
5.
Does client currently use any tobacco products?
(Not including nicotine replacement)
1. No
2. Yes
Tobacco products used (Check all that apply):
1. Cigarettes
2. Cigar
3. Pipe
4. Chewing Tobacco
Secondary Drug Problem:
Number of cigarettes smoked per day (Indicate number of cigarettes-not
number of packs, 1 pack=20 cigarettes; 0=none)
cigarettes
Does the client want to stop using tobacco or cut down from their current
tobacco use?
1. Quit
2. Cut Down
3. No
Is the client currently using any Nicotine Replacement Therapy?
(Check one of the following)
1. No
2. Gum
3. Patch
4. Other
Does the client have a disease or symptoms that they believe
are caused by or made worse by smoking or other tobacco use?
1. No
2. Yes
Number of past attempts to stop smoking or stop tobacco use
times
Age at first use for Secondary
Primary Drug Problem:
years-old
Route of Administration (Secondary Drug):
Drug Name:
1. Alcohol
2. Heroin
3. Marijuana/Hashish
4. Cocaine – Powder
5. Crack
6. Amnphetemines/Methamphetamines
7. Barbituates
8. Benzodiazepine
9. Ecstacy
10. GHB
11. Hallucinogens – LSD
12. Hallucinogens – PCP
13. Hallucinogens – Other
14. Inhalants
15. Ketamine, Special K
16. Methadone (non-prescription)
17. Opiate – Other
18. Oxycontin
19. Rohypnol (Roche, Rope, Roach)
20. Other
1.
2.
3.
4.
5.
6.
Oral
Inhalation/Sniffing
Smoking
Intramuscular/sub-cutaneous
Intravenous
N/A
Tertiary Drug Problem:
Drug Name:
1. Alcohol
2. Heroin
3. Marijuana/Hashish
4. Cocaine – Powder
5. Crack
6. Amphetemines
7. Barbituates
8. Benzodiazepine
9. Ecstacy
10. GHB
11. Hallucinogens – LSD
12. Hallucinogens – PCP
13. Hallucinogens – Other
14. Inhalants
15. Ketamine, Special K
16. Methadone (non-prescription)
17. Opiate – Other
18. Oxycontin
19. Rohypnol (Roche, Rope, Roach)
20. Other
21. None
Frequency of Use (Primary Drug):
1. No use past month
2. Less than weekly
3. 1 to 2 times per week
4. 3 to 6 times per week
5. Daily
NJSAMS Data Entry Forms
Drug Name:
1. Alcohol
2. Heroin
3. Marijuana/Hashish
4. Cocaine – Powder
5. Crack
6. Methamphetamines
7. Barbituates
8. Benzodiazepine
9. Ecstacy
10. GHB
11. Hallucinogens – LSD
12. Hallucinogens – PCP
13. Hallucinogens – Other
14. Inhalants
15. Ketamine, Special K
16. Methadone (non-prescription)
17. Opiate – Other
18. Oxycontin
19. Rohypnol (Roche, Rope, Roach)
20. Other
21. None
22. Other Amphetemines
Frequency of Use (Secondary Drug):
1. No use past month
2. Less than weekly
3. 1 to 2 times per week
4. 3 to 6 times per week
5. Daily
6. N/A
Prior to coming to this facility, estimate how soon (in minutes) after
The Client wakes, do they use tobacco or smoke their first cigarette?
Age at first use for Primary
Oral
Inhalation/Sniffing
Smoking
Intramuscular/sub-cutaneous
Intravenous
years-old
Page 3 of 9
Any questions please call (609) 292-1466, (609) 943-5905
(Admission Contd ……)
If “Other Special Initiatives” is selected, specify
reimbursement source ____________________________
Frequency of Use (Tertiary Drug):
1. No use past month
2. Less than weekly
3. 1 to 2 times per week
4. 3 to 6 times per week
5. Daily
6. N/A
2.Criminal Justice
a. DAS Funded
1. Mutual Agreement Program (MAP)
2. Drug Court (Prison Bound) – Residential
3. Drug Court (Prison Bound) – Aftercare
4. Drug Court (Non-Prison Bound) – OJP
5. Juvenile Justice Initiative
6. DWI/DUI Grants
Age at first use for Tertiary
Route of Administration of Tertiary Drug):
1. Oral
2. Inhalation/Sniffing
3. Smoking
4. Intramuscular/sub-cutaneous
5. Intravenous
6. N/A
In the past 30 days, has client lived in a 24-hour controlled environment
such as Prison, Jail, Residential Drug Treatment Program,? (If client has
lived more than one controlled environment, select 2 choices)
3. Public Assistance
1. TANF
2. General Assistance
3. Food Stamps
4. Charity Care
5. Medicaid
6. Medicare
7. NJ Family Care
1. No
2. Jail
3. Alcohol/Drug Treatment
4. Medical Treatment
5. Psychiatric Treatment
6. Other
In the past 30 days, all together how many days did client live in a
controlled environment? (enter number of days 0 thru 30)
4.County LACADA
1. Chapter 51
2. Enhancement
3. PRCC
4. Direct County Funding
5. Sub-Acute Detoxification
6. Youth Service Commission
7. Other
In the past 30 days, how many days has the client been treated as an
outpatient for alcohol or drug problems?
(enter number of days 0 thru 30)
days
In the past 30 days, has the client been treated in an
emergency room for alcohol/drug problems?
1. No
2. Yes
How many days did the client wait to enter treatment
since first requesting admission from this agency?
(enter number of days 0 thru 30)
5.Other Funding
1. Division of AIDS Prevention and Control
2. Division of Family Health Services
3. Division of Mental Health Services
4. Division of Youth and Family Services (DYFS)
5. Ryan White
6. Private Insurance
7. Client Fees or Family Payment
8. No reimbursement Source/No fee
9. Other
days
REIMBURSEMENT SOURCE (Check all that Apply)
1. Division of Addiction Services
If “Other” is selected, specify _________________
a. Block Grant
1.
2.
3.
4.
General DAS Funding
Block Grant Set-Aside, Women’s
Block Grant Set-Aside, HIV
Block Grant Set-Aside, Other
Gambling Questions
1. Have you often spent a lot of time thinking about past gambling
experience or planning future gambling ventures or bets?
1. No
2. Yes
b. Special Initiatives
1. Targeted capacity Expansion
2. South Jersey Initiative
3. DYFS/Women and Children
4. CWRP Adult
5. CWRP Adolescent
6. Deaf, Hard of Hearing and Disabled
7. DEDR – HIV Prevention
8. Work First Substance Abuse Initiative
9. Compulsive Gambling
10.
IDRC Expansion Fund
11.
WTC-New Jersey Recovers
12.
Other Special Initiatives
NJSAMS Data Entry Forms
b. Other Funded
1. Residential Community Release Program
2. Residential Parole Violator Program
3. Parole Day Reporting/Aftercare
4. Juvenile Justice Commission
5. Administrative Office of the Courts
6. Probation Aftercare – US Dept. of Justice
2. Have you ever lied to family members, friends or others about how
often you gamble or how much money you lost gambling?
1. No
2. Yes
3. After losing at gambling, do you try to return as quickly as possible to
win back your losses
1. No
2. Yes
………… End of Admission …………….
Page 4 of 9
Any questions please call (609) 292-1466, (609) 943-5905
DISCHARGE MODULE
Client Information
Employment /Living, Legal/Drug Use
Date of Admission:
(to this level of care)
/
/
/
Employment status of the client at the time of discharge
1. Full-time work or military (35 hours a week or more)
2. Part-time (regular hours)
3. Part-time (not regular hours)
4. Student
5. Home Maker
6. Retired or Disabled
7. Unemployed - Actively looking for work
8. Unemployed - Not looking for work
9. Unemployed - Volunteer work
10. Living in an institution, like a jail or prison, hospital or overnight
treatment program
/
Client’s:
________________ ___________ ____________________
First name
Middle name Last name
Address : _____________________________________________
City, State, Zip ________________________________________
Email: _________________________________
Living arrangement at discharge
1. Homeless-Shelter
2. Homeless-Streets
3. Dependent Living/Institution
4. Independent Living
Gender (M/F):
Is the client using drugs or alcohol at Discharge? (check all that apply)
Phone #: (______) ______ - __________
Yes, Alcohol
Social Security# -
-
-
Yes, Drug
No
Case No:
Unknown
Name of Primary Drug at Discharge:
Date of birth:
In-House Case #
Date of Discharge:
Date Entered:
/
Drug Name:
1 = Alcohol
2 = Heroin
3 = Marijuana/Hashish
4 = Cocaine - Powder
5 = Crack
6 = Amnphetemines/ Methamphetamines
7 = Barbituates
8 = Benzodiazepine
9 = Ecstacy
10 = GHB
11 = Hallucinogens - LSD
12 = Hallucinogens - PCP
13 = Hallucinogens - Other
14 = Inhalants
15 = Ketamine, Special K
16 = Methadone (non-prescription)
17 = Opiate - Other
18 = Oxycontin
19 = Rohypnol
20 = Other
21 = None
/
_________________
/
/
// /
/
Contact name: _________________________________
Contact Address:
____________________________________________
Contact Phone: (______) ______ - __________
Contact Email: ___________________________
Contact City, State, Zip
Frequency of Use (Primary) at Discharge:
1. No use past month
2. Less than weekly
3. 1 to 2 times per week
4. 3 to 6 times per week
5. Daily
6. N/A
Are you currently enrolled in school or a job training program?
1.Not enrolled
(If not enrolled answer the following if applicable..)
1.Dropped out
2.Expelled
3.Suspended
4.Medical Leave
5.Home Study
6.Other
2.Enrolled Full –Time
3.Enrolled Part –Time
Route of Administration of Primary Drug
1. Oral
2. Inhalation/Sniffing
3. Smoking
4. Intramuscular/sub-cutaneous
5. intravenous
6. N/A
4.other
NJSAMS Data Entry Forms
Page 5 of 9
Any questions please call (609) 292-1466, (609) 943-5905
(Discharge Contd…..)
Route of Administration of Tertiary
1. Oral
2. Inhalation/Sniffing
3. Smoking
4. Intramuscular/sub-cutaneous
5. intravenous
6. N/A
Name of Secondary Drug at Discharge:
Drug Name:
1 = Alcohol
2 = Heroin
3 = Marijuana/Hashish
4 = Cocaine - Powder
5 = Crack
6 = Amnphetemines/ Methamphetamines
7 = Barbituates
8 = Benzodiazepine
9 = Ecstacy
10 = GHB
11 = Hallucinogens - LSD
12 = Hallucinogens - PCP
13 = Hallucinogens - Other
14 = Inhalants
15 = Ketamine, Special K
16 = Methadone (non-prescription)
17 = Opiate - Other
18 = Oxycontin
19 = Rohypnol
20 = Other
21 = None
What is your Current Legal Status?
1. No Legal Problem
2. Case Pending
3. Drug Court
4. Probation
5. Parole
6. DWI License Suspension
7. Jail/Prison Inmate
8. DYFS or Family Court
9. Other
If other; Specify __________________
How many times has client been arrested and charged for
an offense in the past 30 days? (or, since admission if client
in Tx. Less than 30-days
times
Target Population
Frequency of Use (Secondary) at Discharge:
1. No use past month
2. Less than weekly
3. 1 to 2 times per week
4. 3 to 6 times per week
5. Daily
6. N/A
Does the client belong to nay of the following target populations?
Active DYFS Case
Compulsive Gambler
DWI/DUI – Alcohol only
DWI/DUI – Drug only or combination
Route of Administration of Secondary
1. Oral
2. Inhalation/Sniffing
3. Smoking
4. Intramuscular/sub-cutaneous
5. intravenous
6. N/A
DWI/DUI – Boaters and Non-auto
AIDS Diagnosis
HIV Infected
Name of Tertiary Drug at Discharge:
(target population contd..)
Drug Name:
1 = Alcohol
2 = Heroin
3 = Marijuana/Hashish
4 = Cocaine - Powder
5 = Crack
6 = Amnphetemines/ Methamphetamines
7 = Barbituates
8 = Benzodiazepine
9 = Ecstacy
10 = GHB
11 = Hallucinogens - LSD
12 = Hallucinogens - PCP
13 = Hallucinogens - Other
14 = Inhalants
15 = Ketamine, Special K
16 = Methadone (non-prescription)
17 = Opiate - Other
18 = Oxycontin
19 = Rohypnol
20 = Other
21 = None
Blind/Visually Impaired
Deaf/Hard of Hearing
Disabled – Physical
Disabled – Cognitive/Developmental
Disability
Mental Illness/Co-occurring Disorder
None of the above
Psychiatric Diagnosis: (Required for Mental Health Agencies; Optional
for others)
1.
_________
2.
_________
Significant Problems
Frequency of Use (Tertiary) at Discharge:
1. No use past month
2. Less than weekly
3. 1 to 2 times per week
4. 3 to 6 times per week
5. Daily
6. N/A
Significant Problems and Conditions Present at Admission or Identified
During Treatment?
Not Applicable
Mental Health Problem
Compulsive Gambling
Physical Disability/Handicap
NJSAMS Data Entry Forms
Page 6 of 9
Any questions please call (609) 292-1466, (609) 943-5905
Victim of Physical Abuse/Neglect
Non-Agency Referrals for Other Supportive Services
Victim of Sexual Abuse
Referrals for Supportive Services Provided during Treatment
Pregnancy

None
Suicide Attempt

Clergy
Runaway Behavior

Educational
Neglect/Abuse of Client’s
Children

Legal

Medical

Mental Health

Public Welfare

Pre-Natal

Family Services

Vocational Rehab.

Housing

Social Services

Employment

Food Stamps/Food

Women’s Center

Gambling

HIV/AIDS Services

TB Services

Tobacco

Other
Child of Substance Abuser
Batterer
Criminal Activity
Other
If “Other”, specify
________________
Tobacco Use Questions
The client believes the tobacco free policy has helped them to address
their own tobacco use;
1. No
2. Yes
The client is known to have smoked or used tobacco during treatment
at his facility;
1.
No
2.
Yes
The client plans to abstain from all tobacco products after discharge
from this facility;
1. No
2. Yes
If “Other” is selected, specify_______________________
(Discharge Contd…..)
Units of Service for Client - Non-Residential (days/sessions)
The client plans to seek help/treatment for tobacco after discharge
from this facility;
1. No
2. Yes
The client is leaving the facility prematurely mainly because of problems
with the tobacco free policy
1. No
2. Yes
Number of days the client used Nicotine Replacement
(nicotine patch or gum) while in the facility;
days
Non-Agency Referral
Non-Agency Referrals for Substance Abuse Services
Employee/Student Assist. Program
(EAP)
Medication
Medication Prescribed to Treat Substance Abuse
(Check all that apply)

None

Antabuse

Methadone

LAAM

Buprenorphine

Psychotropic Medication

Other
Alcoholics Anonymous (AA)
Services Received by Agency during the treatment
Narcotics Anonymous (NA)
(Check all that apply)
Family-Oriented Self-Help Program

Anger Management/Resolution Interventions
Other Self-Help Program

Case Mgmt: DYFS or Other Child Protective Services

Case Mgmt: Judge or Court
If “Other Self-Help Program” is selected, specify: ______________
NJSAMS Data Entry Forms
days
Units of Service for Codependents Not Reported Separately
(days/sessions)
days
Page 7 of 9
Any questions please call (609) 292-1466, (609) 943-5905

Case Mgmt: Parole or Probation
3. Negative, Date :_____________________

Case Mgmt: Public Assistance (TANF, WIC, Food Stamps,
etc.)
4. Refused

Case Mgmt: Other
6. Hep. Test Done, Not Read

Counseling -Family
7. Other, Specify :____________________

Counseling - Group
8. Unknown

Counseling - Individual
Hepatitis treatment Started? [Complete only if TEST is “Positive”]

Education Services
1. Yes. Date Started :_________________-

Housing Assistance
2. No, [Check Reason below]:

Job/Vocational Assessment, Training
1.
Prior Adequate Treatment

Legal Assistance or Services
2.
Refused

Medical Testing or Services
3.
Discharged Prior to starting

Mental Health Testing or Services
4.
Referred for Treatment to: __________________

Parenting/ Family Interventions
5.
Medically Contra-indicated, Specify: ______________

Personal Needs: Food, Clothing

Rape/Sexual Abuse Interventions

Self-Help: Alcoholics Anonymous

Self-Help: Narcotics/ Cocaine Anonymous and other

HIV/AIDS Services

TB Services

Other
5. Not offered
Did Client have HIV test at this facility?
1 Tested
2 Offered but refused
3 Not Offered
4 Unknown
If tested, did client get HIV test result?
1=Yes
2=Client refused result
3=Client discharged before results given]
Was any urine analyzed for illegal drugs?
1. yes
2. no
3. Unknown
TB Test
/
Date of Data Entry:
/
How many test were done?
Was any Mantoux Tuberculin Skin Test (TST) taken during this
Treatment?
1. Positive at this facility, Date : ________
2. Documented Positive at other facility, Date : _________
3. Negative, Date : __________
4. Refused
5. Not offered
6. Mantux TST Given, Not Read
7. Other, Specify : ____________
8. Unknown
tests
How many test were positive for drugs?
Positive tests
TB treatment Started? [Complete only if TST is “Positive”]
1. Yes. Date Started : ______________
2. No, [Check Reason below]
1.
2.
3.
4.
Documented Prior Adequate Treatment
Refused
Discharged Prior to starting
Referred for Treatment to:
____________________
5.
Medically Contra-indicated; Specify:
______________
Was any Hepatitis Test during the treatment?
1. Positive at this facility, Date : _____________________
Hepatitis Type
A
B
C
D
E
2. Positive at other facility, Date : ____________________
Hepatitis Type
NJSAMS Data Entry Forms
A
B
C
D
E
Page 8 of 9
Any questions please call (609) 292-1466, (609) 943-5905
GOAL ACHIEVEMENT
Partially
Achieved
Achieved
Not
Achieved
Not
Applicable
Alcohol/Drug
Problem
o
o
o
o
Educational
o
o
o
o
Employment/
Vocational
o
o
o
o
Legal
o
o
o
o
Family
Situation/
Social
o
o
o
o
Psychological/
Mental Health
o
o
o
o
Physical Health
o
o
o
o
Level of Care (LOC):
1. Standard/Traditional Outpatient
2. Intensive Outpatient
3. Partial Hospitalization
4. Transitional Care/ Extended Care
5. Halfway House
6. Long-Term Residential
7. Short-Term Residential (Medically Monitored)
8. Hospital-Based (acute) Residential
9. Detox-Free-Standing Residential (Sub-Acute)
10. Detox-Hospital Inpatient
11. Detox-Outpatient (Non-Methadone)
12. OPIOID Maintenance-Outpatient
13. Detox-Mehtadone Outpatient
14. Non-Traditional Program
15. OPIOID Maintenance-Intensive Outpatient
Continuing Care (Non-NJSAMS TX. Agency/ Private Clinic, etc.)
Specify (Non-NJSAMS TX Agency/Private Clinic) :
___________________________
Client signed consent to release records to referral to continuing
care agency:
1. Yes
2. No
Date of Last Face to Face Contact with Client:
/
/
Discharge/ Continuing Care
Reason for Discharge
1. Treatment plan completed at this level of care
2. Treatment plan not completed
If the answer is “Treatment plan not completed”
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Quit or dropped out
Client needs different level of care
Unable to meet client's non-substance abuse treatment needs
Non-compliance with agency rules
Exhaustion of insurance benefits or ability to pay
Loss of eligibility for Medicaid or Medicare
Incarcerated - status revocation
Incarcerated - Charge prior to entering treatment
Incarcerated - Charge since entering treatment
Hospitalized
Decease
Other
If “Other” is selected, specify ___________________
Continuing Care Type
1.
2.
3.
4.
5.
No continuing substance abuse treatment needed
Refused continuing care
Transfer to different level of care within same agency and
clinic site
Transfer to a new clinic site location within same agency
Continuing care coordinated with new agency
Continuing Care NJSAMS TX. Agency/Site ID __________________
NJSAMS Data Entry Forms
Page 9 of 9
Any questions please call (609) 292-1466, (609) 943-5905
NJSAMS Data Entry Forms
Page 18 of 18
Any questions please call (609) 292-1466, (609) 943-5905