CLIENT INFO SCREEN
CLIENT DATA ELEMENTS |
First Name |
Last Name |
Last Name at Birth |
Date of Birth |
Gender |
Preferred Language of Service |
City |
County |
Complete Postal Code |
Ethnicity |
DATIS Key |
Client Site Number |
Address Effective Date |
ADMISSION INFO SCREEN
CLIENT DATA ELEMENTS |
Legal Status |
Young Offender |
Relationship Status |
Treatment Mandated/Required By |
Relationship Status |
Employment Status |
Education |
Income Source |
Presenting Problem Substance # 1 |
Frequency in Last 30 days (PPS # 1) |
Substances Used in last 12 months |
Gambling Identified as Problem |
Gambling Activities engaged in the past 12 months |
Vision Problems |
Mobility Problems |
Hearing Problems |
Pregnancy Status |
Non-medical intravenous drug use |
Number of overnight hospitalizations in the last 12 months for physical problems |
CLIENT DATA ELEMENTS |
Diagnosed with a mental health problem by a qualified mental health professional within the last 12 months |
Diagnosed with a mental health problem by a qualified mental health professional within lifetime |
Receiving treatment for a mental health, emotional, behavioural or psychological problem from a qualified mental health program or professional currently |
Receiving treatment for a mental health, emotional, behavioural or psychological problem from a qualified mental health program or professional within last 12 months |
Receiving treatment for a mental health, emotional, behavioural or psychological problem from a qualified mental health program or professional within lifetime |
Prescribed medication for a mental health problem currently |
Prescribed medication for a mental health problem currently |
Prescribed medication for a mental health problem within lifetime |
Methadone/opioid substitute |
AGENCY DATA ELEMENTS |
Site Number |
(Client) Admission Date |
Primary Worker |
Referred On |
Referring Source |
Client Type |
PROGRAM INFORMATION SCREEN
AGENCY DATA ELEMENTS |
Program Name |
Site Number |
Start Date |
Start Time |
End Date |
End Time |
Reason For Termination |
Direct Service Time (Total Hours) |
Indirect Service Time (Total Hours) |
Total Sessions |
DISCHARGE INFORMATION SCREEN
AGENCY DATA ELEMENTS |
Discharge Date |
Reason for Discharge |
Referral Made |
REFERRAL INFORMATION SCREEN
AGENCY DATA ELEMENTS |
Refer to Provincial Service Category |
Refer to Service Type |
Referred on |
