Attachment 3 Child, Adolescent Tool
The Consumer Level National Outcome Measures (NOMs)
Attach-3-TRAC Child NOMs Child Respondent Survey
CMHS NOMs
OMB: 0930-0285
Form Pending Approval
OMB No. xxxx-xxxx
Expiration Date xx/xx/xxxx
CMHS NOMS Child Consumer Outcome
Measures for Discretionary Programs
Child or Adolescent Respondent Version
Public reporting burden for this collection of information is estimated to average 20 minutes per response if all items are asked of a client/participant; to the extent that providers already obtain much of this information as part of their ongoing client/participant intake or followup, less time will be required. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-xxxx.
A. RECORD MANAGEMENT
Consumer ID |____|____|____|____|____|____|____|____|____|____|____|
Grant ID (Grant/Contract/Collaborative Agreement) |____|____|____|____|____|____|____|____|____|____|
Site ID |____|____|____|____|____|____|____|____|____|____|
Interview Type [Select only one]
Baseline
Did you conduct a baseline interview?
Yes [Select a consumer type then fill in the interview date and the rest of Section A]
No [Select a consumer type then fill in the rest of Section A]
Consumer Type [Select only one]
New [A first-time consumer to your grant]
Continuing [A consumer who was previously screened, assessed, treated, or referred
by your grant]
3 month reassessment [All programs except CMHI and Jail Diversion]
Did you conduct a reassessment interview?
Yes [Fill in interview date, then skip to Section B]
No [Skip to Section I]
6 month reassessment [CMHI and Jail Diversion]
Did you conduct a reassessment interview?
Yes [Fill in interview date, then skip to Section B]
No [Skip to Section I]
Clinical Discharge
Did you conduct a discharge interview?
Yes [Fill in interview date, then skip to Section B]
No [Skip to Section J]
Interview Date |____|____| / |____|____| / |____|____|____|____|
Month Day Year
RECORD MANAGEMENT (Continued) - DEMOGRAPHICS
[Demographics are collected only at the baseline interview]
1. What is your gender?
Male
Female
Transgender
Other (Specify) _____________________________________
Refused
2. Are you Hispanic or Latino?
Yes
No
Refused
[If Yes] What ethnic group do you consider yourself? Please answer yes or no for each of the following. You may say yes to more than one.
Yes No Refused
Central American
Cuban
Dominican
Mexican
Puerto Rican
South American
Other [If Yes, Specify Below]
(Specify) ______________________________
What race do you consider yourself? Please answer yes or no for each of the following. You
may say yes to more than one.
Yes No Refused
Black or African American
Asian
Native Hawaiian or other Pacific Islander
Alaska Native
White
American Indian
Other [If Yes, Specify Below]
(Specify) ______________________________
4. What is your month and year of birth?
|____|____| / |____|____|____|____|
Month Year
Refused
[For CMHI grantees that are sampling, if the consumer is not part of the sample, stop here. No additional information is required.]
B.
FUNCTIONING
In order to provide the best possible mental health services, we need to know what you think about how well you were able to deal with your everyday life during the last 30 days. Please indicate your agreement/disagreement with each of the following statements.
[Read each statement followed by the response options to the child/adolescent]
STATEMENT |
RESPONSE OPTIONS |
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Strongly Disagree |
Disagree |
Undecided |
Agree |
Strongly Agree |
Refused |
1. I am handling daily life. |
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2. I get along with family members. |
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3. I get along with friends and other people. |
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6. I am satisfied with our family life right now. |
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[Optional: GAF score reported by program staff at program’s discretion]
What was the consumer’s score? GAF = |____|____|____|
Date GAF was administered: |____|____| / |____|____| /|____|____|____|____|
Month Day Year
C. STABILITY IN HOUSING
1. In the past 30 days, where have you been living most of the time?
[Do not read response options to the child/adolescent. Select only one.]
Caretaker’s owned or rented house, apartment, trailer, or room
Someone else’s house, apartment, trailer, or room
Homeless (Shelter, street/outdoors, park)
Group home
Foster care (Specialized Therapeutic Treatment)
Transitional living facility
Halfway house
Residential Treatment Center
Hospital (Medical)
Hospital (Psychiatric)
Correctional facility (Juvenile Detention Center/Jail/Prison)
Other Housed (Specify) _______________________________________________
Refused
Don’t Know
Who have you lived with during the past 30 days? You may choose more than one answer.
Biological parent(s)
Adoptive parent(s)
Relative other than parent(s)
Non-relative
Independent living
Refused
Don’t Know
D. EDUCATION
During the last 30 days of school, how many days were you absent for any reason?
0 days
1 day
2 days
3 to 5 days
6 to 10 days
More than 10 days
Refused
Don’t Know
Not Applicable
a. How many days were unexcused absences?
0 days
1 day
2 days
3 to 5 days
6 to 10 days
More than 10 days
Refused
Don’t Know
Not Applicable
What is the highest level of education you have finished, whether or not you received a degree?
Never Attended
1ST Grade
2ND Grade
3RD Grade
4TH Grade
5TH Grade
6TH Grade
7TH Grade
8TH Grade
9TH Grade
10TH Grade
11TH Grade
12TH Grade/High school diploma/Equivalent (ged)
Voc/Tech diploma
Some college or university
Refused
Don’t Know
E. CRIME AND CRIMINAL JUSTICE STATUS
1. In the past 30 days, how many times have you been arrested?
|____|____| Times Refused Don’t Know
[For baseline interviews, skip to Section G]
F. PERCEPTION OF CARE
[Section F is collected only at the reassessment or the discharge interview]
[For baseline interviews, skip to Section G]
In order to provide the best possible mental health services, we need to know what you think about the services you received during the last 30 days, the people who provided it, and the results. Please indicate your agreement/disagreement with each of the following statements.
[Read each statement followed by the response options to the child/adolescent]
STATEMENT |
RESPONSE OPTIONS |
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Strongly Disagree |
Disagree |
Undecided |
Agree |
Strongly Agree |
Refused |
1. Staff here treated me with respect. |
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2. Staff respected my family’s religious/spiritual beliefs. |
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3. Staff spoke with me in a way that I understood. |
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4. Staff was sensitive to my cultural/ethnic background. |
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5. I helped to choose my services. |
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6. I helped to choose my treatment goals. |
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7. I participated in my treatment. |
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8. Overall, I am satisfied with the services I received. |
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9. The people helping me stuck with me no matter what. |
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10. I felt I had someone to talk to when I was troubled. |
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11. The services I received were right for me. |
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12. I got the help I wanted. |
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13. I got as much help as I needed. |
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G. SOCIAL CONNECTEDNESS
Please indicate your agreement/disagreement with each of the following statements. Please answer for relationships with persons other than your mental health provider(s) over the past 30 days.
[Read each statement followed by the response options to the child/adolescent]
STATEMENT |
RESPONSE OPTIONS |
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Strongly Disagree |
Disagree |
Undecided |
Agree |
Strongly Agree |
Refused |
1. I know people who will listen and understand me when I need to talk. |
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2. I have people that I am comfortable talking with about my problems. |
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3. In a crisis, I would have the support I need from family or friends. |
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4. I have people with whom I can do enjoyable things. |
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[If this is a baseline interview stop now, the interview is complete.]
[If this is a reassessment interview (3 or 6 month) go to the next page, Section I.]
[If this is a clinical discharge interview, skip to Section J.]
I. REASSESSMENT STATUS
[Section I is reported by program staff only at reassessment]
1. What is the reassessment status of the consumer?
[This is a required field: NA, Refused, Don’t Know, and Missing will not be accepted]
01 = Deceased at time of due date
11 = Completed interview within specified window
12 = Completed interview outside specified window
21 = Refused interview
31 = No contact within 90 days of last encounter
32 = Other (Specify) ________________________
2. Is the consumer still receiving services from your program?
Yes
No
[Skip to Section K]
J. CLINICAL DISCHARGE STATUS
[Section J is reported by program staff only if a consumer is discharged from the program]
1. On what date was the consumer discharged?
|____|____| / |____|____| / |____|____|____|____|
Month Day Year
2. What is the consumer’s discharge status?
01 = Mutually agreed cessation of treatment
02 = Death
03 = No contact
04 = Clinically referred out
05 = Other (Specify) __________________________________
[Go to next page, Section K]
K. SERVICES RECEIVED
[Section K is reported by program staff only at reassessment or discharge]
1. On what date did the consumer last receive services?
|____|____| / |____|____| / |____|____|____|____|
Month Day Year
[Identify all of the services your program provided to the consumer since his/her last NOMs interview; this includes CMHS-funded and non-funded services.]
Core Services Provided
Yes No
1. Screening
2. Assessment
3. Treatment Planning or Review
4. Psychopharmacological Services
5. Mental Health Services
[If Yes, please select the frequency mental health services were delivered]:
Daily Weekly Monthly Less than Monthly
6. Co-Occurring Services
7. Case Management
8. Trauma-specific Services
9. Was the consumer referred to another provider for any of the above core services?
Yes No
Support Services Provided
Yes No
1. Primary Care
2. Employment Services
3. Family Services
4. Child Care
5. Transportation
6. Education Services
7. Housing Support
8. Social Recreational Activities
9. Consumer Operated Services
10. Medical Support & HIV Testing
11. Was the consumer referred to another provider for any of the above support services?
Yes No
| File Type | application/msword |
| File Title | Form |
| Author | David Rockwell |
| Last Modified By | Jessica Taylor |
| File Modified | 2006-12-13 |
| File Created | 2006-12-11 |
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