<PreEncounter>
	<SenderData ProviderName="My Org" ProviderETIN="94203283999" BatchNumber="20060504-002"/>
	<DocumentFunction DocumentNumber="20060504-002-001" DocumentFunction="1">
		<ConsumerData>
			<Name LastName="Smith" FirstName="John" MiddleName="M" Prefix="Mr"/>
			<Demographics Gender="01" DateOfBirth="1958-03-23" HearingStatus="144" PreferredLanguage="164" EmploymentStatus="8" SSN="000-00-0000" MaritalStatus="1" Occupation="01"/>
			<Address Street1="923 10th Street West" City="Jefferson City" State="MO" County="099" Country="US" Zip="63405-2345"/>
			<Race White="0" Black_AfricanAmerican="1" Asian="0" NativeHawiian_PacificIslander="0" AmIndian_NativeAlaskan="0" OtherRace="0" NotOfHispanicOrigin="1" Hispanic_Mexican="0" Hispanic_Cuban="0" Hispanic_PuertoRican="0" OtherHispanic="0"/>
		</ConsumerData>
		<EpisodeCare Division="ADA" EnrollingProviderSiteName="Jefferson" EnrollingProviderSiteID="413" AdmissionDateTime="2006-03-12 02:00 PM" AdmissionReason="1" ReferralSource="19" LocalChartNumber="45784" FamilySize="1" NumberOfChildrenInCare="0">
			<Diagnosis Axis="1" DiagnosisDateTime="2006-03-12 02:00 PM" DiagnosticianName="John Matrix" DiagnosisCodeSet="ICD-9" DiagnosisCode="300.1" Status="Admission" Severity="Moderate" Principal="1" Primary="1"/>
			<Diagnosis Axis="2" DiagnosisDateTime="2006-03-16 09:00 AM" DiagnosticianName="John Matrix" DiagnosisCodeSet="DSM-IV" DiagnosisCode="625.8 " Status="Admission" Severity="Severe" Principal="0" Primary="0"/>
			<Diagnosis Axis="3" DiagnosisDateTime="2006-03-16 09:00" DiagnosticianName="John Matrix" DiagnosisCodeSet="ICD-9" DiagnosisCode="005.0" Status="Current" Severity="Mild" Principal="0" Primary="0"/>
			<Diagnosis Axis="4" DiagnosisDateTime="2006-03-16 13:00" DiagnosticianName="John Matrix" Status="Current" Severity="Catastrophic" StressorCategory="4" Chronicity="Acute"/>
			<Diagnosis Axis="5" DiagnosisDateTime="2006-03-16 13:00" DiagnosticianName="John Matrix" CurrentGAF="32"/>
			<Commitments CommitmentType="200" CommitmentFromDate="2006-03-12" CommitmentCounty="099" PrimaryIndicator="1"/>
			<Commitments CommitmentType="300" CommitmentFromDate="2006-03-12" CommitmentCounty="099" PrimaryIndicator="0" CommitmentToDate="2006-03-15"/>
			<ProgramAssignment Program="ADACompGamb" ProgramFromDate="2006-03-12" ProgramFromTime="14:00" Status="1" LivingArrangement="09" ProgramLevel="1Basic"/>
			<ProgramAssignment Program="ADASATOPAdCLInt" ProgramFromDate="2006-03-12" ProgramFromTime="14:00" Status="1" LivingArrangement="09">
				<ADAProgramAssignment DateInfoReceivedfromConsumer="2006-03-12" CodependentIndicator="0" ServiceCounty="099" PsychologicalProblemIndicator="0" DevelopmentProblemIndicator="0" TuberculosisTreatmentIndicator="0" VeteranStatusIndicator="1" EnrolledInSchool="0" PriorDetox="1" PriorResidential="0" PriorOutpatient="1" NumberofArrests="2" NumberofDUIArrests="2" IncomeSource="2" PrimarySourcePayment="07" WeeklyIncomeCode="Over" MonthlyIncomeAmt="3000" LegalStatus="2" LivingArrangement="09" Education="19" SpecialEducation="19" PrimarySubstanceAbused="0201" PrimarySAFrequency="02" PrimarySARoute="1" PrimarySAAgeFirstUsed="18" SecondarySubstanceAbused="1201" SecondarySAFrequency="02" SecondarySARoute="1" SecondarySAAgeFirstUsed="25"/>
				<ADAProgAssignSocialSupportRecovery SocialSupportRecoveryActivities="OTHER"/>
				<ADAProgAssignSocialSupportRecovery SocialSupportRecoveryActivities="RELIGIOUS"/>
				<ADAProgAssignPubAsst PublicAssistance="1"/>
				<ADAProgAssignMeds MedicationPrescribed="00"/>
			</ProgramAssignment>
		</EpisodeCare>
	</DocumentFunction>
</PreEncounter>
