Free HSRS Alcohol and Other Drug Abuse Module - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-20458 (Rev. 12/2008)

HSRS ALCOHOL AND OTHER DRUG ABUSE MODULE
REGISTRATION - Screen A3 N, U or I 1 Worker ID 4a Last Name (Module Key: ) MODULE TYPE 6 2 Social Security Number 4b First Name 4c Middle Name 3 Client ID 4d Suffix

STATE OF WISCONSIN SOS Desk (608) 266-9198 Completion of this form meets the requirements of the State / County contract specified under the Wisconsin Statutes. S. 46.031(2g)

5 Birthdate (mm/dd/yyyy)

7a Hispanic/Latino

7b Race (Circle up to 5) 8 Client 9 Start Date 10 Closing Date 11 Co-dependent A=Asian W= White Characteristics Yes B=Black or African American Yes No P=Native Hawaiian or Pacific Islander No I=American Indian or Alaska Native 13 Education at Time 14 Family 15 Number of Arrests 16 Living Arrangement at 17 Brief Service 18 Employment 19 Pregnant at Time of Admission of Admission Relationship 30 Days Prior to Admission Status Admission Yes Yes No No 20 Diagnosis 21 Case Review Date 22 Family ID 23 Local Data 24 Special Project Reporting If "Yes" in fields 11 or 17, skip fields 25-29 Substance Problem Usual Route of Administration Use Frequency Age of First Drug Use or Alcohol Intoxication SERVICES - Screen A4
Prog. No. 30 SPC Sub Prog

6 Sex F M 12 Referral Source

25a Primary 27a Primary 28a Primary 29a Primary )
33 SPC End Date

25b Secondary 27b Secondary 28b Secondary 29b Secondary

25c Tertiary 27c Tertiary 28c Tertiary 29c Tertiary

26 At Discharge

(Module Key:
32 Provider Number

UNITS ­ Screen A7
34 SPC End Reason 35 Closing Status A F E AR LA 36 Target Group 37 SPC Review Date mm yyyy 38 Days of Care 39 Other Units 40 Delivery Date mm yyyy

31 SPC Start Date

OPTIONAL DATA - Screen 18 Street Address Shaded areas are optional.

(Module Key:

) City

State

Zip Code

County

Telephone Number

(

)

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-20458 (Rev. 12/2008)

HSRS ALCOHOL AND OTHER DRUG ABUSE MODULE CO-DEPENDENT OR BRIEF SERVICES
2 Social Security Number 4b First Name 4c Middle Name 3 Client ID 4d Suffix

STATE OF WISCONSIN SOS Desk (608) 266-9198 2

REGISTRATION - Screen A3 N, U or I 1 Worker ID 4a Last Name

5 Birthdate (mm/dd/yyyy)

6 Sex

7a Hispanic/Latino Yes No

7b Race (Circle up to 5)

8 Client Characteristics

9. Start Date

10 Closing Date

F M 11 Co-dependent / Yes No

12 Referral Source

A=Asian W= White B=Black or African American P=Native Hawaiian or Pacific Islander I=American Indian or Alaska Native 17 Brief Service 20 Diagnosis 21 Case Review Date Yes No

22 Family ID

23 Local Data

SERVICES - Screen A4
Prog. No. 30 SPC Sub Prog

(Module Key:
31 SPC Start Date

)
32 Provider Number 33 SPC End Date 36 Target Group 37 SPC Review Date mm yyyy

UNITS ­ Screen A7
39 Other Units 40 Delivery Date mm yyyy

OPTIONAL DATA - Screen 18 Street Address Shaded areas are optional.

(Module Key:

) City

State

Zip Code

County

Telephone Number

(

)