CLIENT INFO SCREEN
CLIENT DATA ELEMENTS |
First Name |
Last Name |
Last Name at Birth |
Date of Birth |
Gender |
| Site Number |
What is your mother tongue? |
| In which of Canada's Official Languages are you most comfortable receiving your health care services? |
In which language are you most comfortable receiving your healthcare services? |
City |
County |
Complete Postal Code |
Ethnicity |
DATIS Key |
Client Site Number |
Address Effective Date |
ADMISSION INFO SCREEN
CLIENT DATA ELEMENTS |
Legal Status |
Young Offender Status |
Relationship Status |
Mandatory/Required Treatment |
Relationship Status |
Employment Status |
Education Status |
Income Source |
Primary Problem Substance |
Frequency of Use of Primary Problem Substance in Prior 30 days |
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 |
Prescribed Methadone or Other Opioid Substitute |
AGENCY DATA ELEMENTS |
Site Number |
Admission Date |
Date of Referral to the Agency |
Referral Source |
Client Type |
PROGRAM INFORMATION SCREEN
AGENCY DATA ELEMENTS |
Program Name |
Program Site Number |
Program Start Date |
Program Start Time |
Program End Date |
Program 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 INFORMATION SCREEN
AGENCY DATA ELEMENTS |
Refer to Provincial Service Category |
Refer to Service Type |
| Referred on |
