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Connecticut Department of Mental Health and Addiction Services

DDaP – UPDATE / DISCHARGE FORM

CCLIENT INFORMATION

NAME:

SOCIAL SECURITY NUMBER

DATE OF BIRTH

ADDRESS:

CLIENT STREET ADDRESS 1

CLIENT STREET ADDRESS 2

CITY:

STATE:

ZIP CODE:

PROVIDER CLIENT ID:

ADMISSION:

ADMISSION DATE:

ADMISSION PROGRAM:

1DDaP Update/Discharge Form: 3-5-14 jg-ISD

DIAGNOSIS


EFFECTIVE DATE OF DIAGNOSIS:		/	/
(Enter Client’s clinical diagnoses below.)		/	/



AXIS I	(Enter Diagnosis)	Description

1___ ___ ___.___ ___ (Primary Dx)

2___ ___ ___.___ ___

3___ ___ ___.___ ___

4___ ___ ___.___ ___

5___ ___ ___.___ ___

6___ ___ ___.___ ___

7___ ___ ___.___ ___

	AXIS II	(Enter Diagnosis)	Description

1___ ___ ___.___ ___

2___ ___ ___.___ ___

3___ ___ ___.___ ___

4___ ___ ___.___ ___

5___ ___ ___.___ ___

AXIS III

(Enter Diagnosis)

Description

1___ ___ ___.___ ___

2___ ___ ___.___ ___

3___ ___ ___.___ ___

4___ ___ ___.___ ___

5___ ___ ___.___ ___

AXIS IV (Select Yes or No)

2		PROBLEMS RELATED TO THE SOCIAL ENVIRONMENT		YES	NO

1		PROBLEMS WITH PRIMARY SUPPORT GROUP		YES	NO

9		OTHER PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS		YES	NO

7		PROBLEMS WITH ACCESS TO HEALTH SERVICES		YES	NO

4		OCCUPATIONAL PROBLEMS		YES	NO

3		EDUCATIONAL PROBLEMS		YES	NO

6		HOUSING PROBLEMS		YES	NO

5		ECONOMIC PROBLEMS		YES	NO

8		PROBLEMS RELATED TO THE LEGAL SYSTEM / CRIME		YES	NO



	AXIS V – GAF SCORE:		(ENTER 0 – 100)

2	DDaP Update/Discharge Form: 3-5-14 jg-ISD

Complete if applicable.

DISCHARGE

DISCHARGE DATE

DISCHARGE REASON: (check one box below)

AMA (AGAINST MEDICAL ADVICE)

LEFT AGAINST ADVICE

AWOL FOR INPATIENT ONLY

MOVED OUT OF AREA

CLIENT DISCONTINUED TX

NON COMPLIANCE WITH RULES

DEATH

OTHER

DISCHARGED TO NEW SERVICE (FACILITY

RECOVERY PLAN COMPLETED

CONCURS)

EVALUATION ONLY

RELEASED BY COURT

INCARCERATED

UNKNOWN

IP DISCHARGE FOR IP MEDICAL TX

PROVIDER SIGNATURE

DATE

PERIODIC ASSESSMENT

ASSESSMENT DATE

EMPLOYMENT STATUS: (check one box only)

EMPLOYMENT FULL TIME (in

NOT IN LABOR FORCE; retired

competitive employment)

EMPLOYMENT PART TIME (in

NOT IN LABOR FORCE; SSI SSDI

competitive employment)

UNEMPLOYMENT (looking for work in

NOT IN LABOR FORCE; Inmate of

the past 30 days, or on a layoff)

institution

PAID BUT NON-COMPETITIVE WORK

NOT IN LABOR FORCE; other reason

(transitional employment programs)

PAID BUT NON-COMPETITIVE WORK

OTHER

(work inside the clubhouse or treatment

agency, mobile work crews and

consumer-run businesses)

NOT IN LABOR FORCE; student

UNKNOWN

enrolled in a school or job training

program)

NOT IN LABOR FORCE; homemaker

HIGHEST GRADE COMPLETED: Highest school grade completed by Client at the time of Assessment.

PERSONS DEPENDENT ON INCOME:

MINORS DEPENDENT ON INCOME:

(Enter 0 – 32)

(Enter 1 – 15)

(Enter 0 – 14)

UNKNOWN

DDaP Update/Discharge Form: 3-5-14 jg-ISD

PRINCIPAL SOURCE OF SUPPORT: (check one box only)

0		NONE	4	DISABILITY
1		PUBLIC ASSISTANCE	96	OTHER
2		RETIREMENT	97	UNKNOWN
				UNKNOWN
3		SALARY


	LIVING SITUATION: (check one box only)
30		PRIVATE RESIDENCE, client owns or	46	PSYCHIATRIC/SA/MEDICAL
		holds lease		INPATIENT
32		PRIVATE RESIDENCE, friend or relative	48	CORRECTIONAL FACILITY
		owns the residence or holds lease.
34		SINGLE ROOM OCCUPANCY (Hotel,	50	DOMESTIC VIOLENCE SHELTER
		YMCA, Rooming House)
36		PRIVATE RESIDENCE, Community	52	HOMELESS SHELTER
		agency owns or holds lease
38		RESIDENTIAL CARE HOME / BOARD	54	HOMELESS (including on street)
		AND CARE		HOMELESS (including on street)
		AND CARE
40		CONGREGATE RESIDENTIAL CARE	96	OTHER
		(24-hour supervision, group setting,		OTHER
		(24-hour supervision, group setting,
		services focus on MH, SA, &/or MR
		issues, Recovery House.)
42		CRISIS / RESPITE BED	97	UNKNOWN
				UNKNOWN
44		SKILLED NURSING FACILTY/
		INTERMEDIATE CARE FACILTY/
		NURSING HOME

Was Client Homeless in the Last Six Months?

Number of Days in the Last 30 that client lived in a Controlled Environment?

Number of Arrests in the Last 30 Days?

SOCIAL SUPPORT VOLUNTARY: Number of Self-Help programs/meetings attended in last 30 days

SOCIAL SUPPORT FAMILY/FRIENDS: Indicate whether or not Client interacted with Family/Friends supportive of recovery in the thirty days preceding assessment.

YES

(Enter 0 – 30)

(Enter 0 – 90)

YES

UNKNOWN

4DDaP Update/Discharge Form: 3-5-14 jg-ISD

PERIODIC ASSESSMENT – SUBSTANCE USE

DRUG TYPE(S) used by clients

DRUG

(Select Drug Type 1 - 5, as applicable)

TYPE 1

TYPE 2

TYPE 3

TYPE 4

TYPE 5

Primary

Secondary

Tertiary

NONE

AMPHETAMINES

ALCOHOL

BARBITUATES

BENZODIAZEPINES

COCAINE

CRACK

HALLUCINOGENS: LSD, DMS, STP, etc.

HEROIN

INHALANTS

MARIJUANA, HASHISH, THC

METHAMPHETAMINES

NON-PRESCRIPTIVE METHADONE

OTHER OPIATES AND SYNTHETICS

OTHER SEDATIVES OR HYPNOTICS

OTHER STIMULANTS

OVER-THE-COUNTER

PCP

TRANQUELIZERS

OTHER

UNKNOWN

DRUG METHOD USE FIELD 1: (Complete based on corresponding DRUG TYPE 1 selected, except 0 & 97.)

ORAL

INJECTION

SMOKING96

INHALATION97

OTHER

UNKNOWN

DAYS USED FIELD 1:

Number of Days in the Last 30 in which the client used the Drug specified		(Enter 0 – 30)
in the Drug Type 1 field?

AGE FIRST USED FIELD	1:
Age at which the client used the Drug specified in the Drug Type 1 field?		(Enter Age)

5DDaP Update/Discharge Form: 3-5-14 jg-ISD

DRUG METHOD USE FIELD 2: (Complete based on corresponding DRUG TYPE 2 selected, except 0 & 97.)


01		ORAL				04	INJECTION
02		SMOKING				96	OTHER
03		INHALATION				97	UNKNOWN


	DAYS USED FIELD 2		:

	Number of Days in the Last 30 in which the client						(Enter 0 – 30)
	used the Drug specified in the Drug Type 2 field?						(Enter 0 – 30)
	used the Drug specified in the Drug Type 2 field?

	AGE FIRST USED FIELD 2				:

	Age at which the client			used the Drug specified in			(Enter Age)
	the Drug Type 2 field?						(Enter Age)
	the Drug Type 2 field?

DRUG METHOD USE FIELD 3: (Complete based on corresponding DRUG TYPE 3 selected, except 0 & 97.)


01		ORAL				04	INJECTION
02		SMOKING				96	OTHER
03		INHALATION				97	UNKNOWN


	DAYS USED FIELD 3		:

	Number of Days in the Last 30 in which the client						(Enter 0 – 30)
	used the Drug specified in the Drug Type 3 field?						(Enter 0 – 30)
	used the Drug specified in the Drug Type 3 field?

	AGE FIRST USED FIELD 3				:

	Age at which the client			used the Drug specified in			(Enter Age)
	the Drug Type 3 field?						(Enter Age)
	the Drug Type 3 field?

DRUG METHOD USE FIELD 4: (Complete based on corresponding DRUG TYPE 4 selected, except 0, 97.)


01		ORAL			04	INJECTION
02		SMOKING			96	OTHER
03		INHALATION			97	UNKNOWN


	DAYS USED FIELD 4:

	Number of Days in the Last 30 in which the client					(Enter 0 – 30)
	used the Drug specified in the Drug Type 4 field?					(Enter 0 – 30)
	used the Drug specified in the Drug Type 4 field?

	AGE FIRST USED FIELD 4			:

	Age at which the client		used the Drug specified in			(Enter Age)
	the Drug Type 4 field?					(Enter Age)
	the Drug Type 4 field?

DRUG METHOD USE FIELD 5: (Complete based on corresponding DRUG TYPE 5 selected, except 0 & 97.)

ORAL

INJECTION

SMOKING96

INHALATION97

OTHER

UNKNOWN

DAYS USED FIELD 5:

Number of Days in the Last 30 in which the client used the Drug specified in the Drug Type 5 field?

AGE FIRST USED FIELD 5:

Age at which the client used the Drug specified in the Drug Type 5 field?

(Enter 0 – 30)

(Enter Age)

6DDaP Update/Discharge Form: 3-5-14 jg-ISD

Question	Answer
Form Name	Ct Ddap Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	form ddap discharge, ct form update, dmhas ddap update discharge, ddap ct

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