DELAWARE DIVISION OF SUBSTANCE ABUSE 
AND MENTAL HEALTH 
CONSUMER REPORTING FORM 
HOSPITAL DISCHARGE REPORT 
DATE OF FIRST TREATMENT 
/ / 
TREATMENT 
UNIT NAME 
LAST NAME 
FIRST NAME 
SUBSTANCE ABUSE - DSM IV DIAGNOSIS (DESIGNATED CODES ONLY) 
AXIS 1: CLINICAL DISORDERS 
• CODE 
• CODE 
• CODE 
SEE DSM IV MANUAL 
USE THESE CODES IN THE AXIS I BOXES ABOVE 
AD / SA Diagnostic Codes 
DSM IV, Axis I Clinical Codes 
INTOXICATION 
303.00 ALCOHOL 
292.89 AMPHETAMINE 
292.89 CANNABIS 
292.89 COCAINE 
292.89 HALLUCINOGEN 
292.89 INHALANT 
292.89 OPIOID 
292.89 PHENCYCLIDINE 
292.89 SEDATIVE, HYPNOTIC & ANXIOLYTIC 
-- POLYSUBSTANCE 
292.89 OTHER (UNKNOWN) 
PERSON COMPLETING FORM 
DATE OF COMPLETION 
/ 
PAGE 1 OF 1 
DATE OF LAST TREATMENT 
/ / 
TREATMENT 
UNIT ID # 
MCI # 
M.I. 
ABUSE WITHDRAWAL 
305.00 291.81 
305.70 292.0 
305.20 -- 
305.60 292.0 
305.30 -- 
305.90 -- 
305.50 292.0 
305.90 -- 
305.40 292.0 
-- 292.0 
305.90 292.0 
ID NUMBER
/ 
ADMISSION DATE 
/ / 
DISCONTINUATION DATE 
/ / 
— 
0 0 0 
DISCONTINUATION REASON 
[ ] G PROGRAM COMPLETED 
HERE - ALL GOALS 
[ ] S PROGRAM COMPLETED 
HERE - SOME GOALS 
[ ] E ELIGIBILITY LAPSED 
[ ] D CONSUMER DIED 
[ ] F FAILED TO MEET CRITERIA 
[ ] A ADMIN. DISCONTINUATION/ 
LOST CONTACT 
[ ] C CORRECTION/JAIL 
[ ] R REFUSED SERVICE 
[ ] T TX CONT. OTHER PROGRAM 
[ ] O OTHER 
[ ] U UNKNOWN 
FUNCTIONING IMPROVED 
[ ] Y YES [ ] U UNKNOWN 
[ ] N NO 
DRUG DEPENDENCE REDUCED 
[ ] Y YES [ ] U UNKNOWN 
[ ] N NO 
[ ] X NOT APPLICABLE 
DEPENDENCE 
PRIMARY DESTIN./AGENCY CODE 303.90 
304.40 
304.30 
304.20 
304.50 
[ ] T TRANSFERRED 
[ ] R REFERRED 
[ ] A ADVISED FURTHER SERVICE 
[ ] N NO MORE SERVICES ADVISED 
[ ] U UNKNOWN 
304.60 
304.00 SECOND. DESTIN./AGENCY CODE 
304.90 
304.10 
304.80 
304.90 
[ ] T TRANSFERRED 
[ ] R REFERRED 
[ ] A ADVISED FURTHER SERVICE 
[ ] N NO MORE SERVICES ADVISED 
[ ] U UNKNOWN 
TERTIARY DESTIN./AGENCY CODE 
[ ] T TRANSFERRED 
[ ] R REFERRED 
[ ] A ADVISED FURTHER SERVICE 
[ ] N NO MORE SERVICES ADVISED 
[ ] U UNKNOWN