Get Residential Disenrollment Assessment Form - Mass.gov - Mass

The Residential Disenrollment Assessment Form is an essential document for individuals involved in residential treatment programs. Filling it out accurately is crucial for proper disenrollment and future care planning.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your ESM Client ID and Provider ID in the designated fields.
3. Complete the disenrollment date using the MM/DD/YYYY format. This date indicates when you are officially disenrolling from the program.
4. Select the reason for disenrollment from the list provided. Ensure that you mark only one reason that aptly fits your situation.
5. Fill in your first name, middle initial (if applicable), and last name in the respective fields.
6. Indicate your client code and client type, selecting either 'Primary' or 'Collateral.'
7. Complete the referral section by providing information about any referrals made during your treatment. You may include up to three referrals.
8. Indicate your employment status at the time of disenrollment, using the relevant codes provided.
9. Answer any questions regarding your usage of drugs or alcohol in the last 30 days, as well as information related to tobacco usage.
10. Fill out the sections regarding your treatment, including any self-help programs attended. Provide details about the social or health services you received during treatment.
11. Once all fields are completed, review your entries for accuracy. Then, save your changes, download, print, or share the form as needed.

Complete your Residential Disenrollment Assessment Form online for a seamless disenrollment process.