Attachment 1 Adult Tool

Form Pending Approval

OMB No. xxxx-xxxx

Expiration Date xx/xx/xxxx

CMHS NOMS Adult Consumer Outcome

Measures for Discretionary Programs

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

1. 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) ______________________________

3. 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

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 consumer]

STATEMENT	RESPONSE OPTIONS
	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree	Refused
1. I deal effectively with daily problems.						
2. I am able to control my life.						
3. I am able to deal with crisis.						
4. I am getting along with my family.						
5. I do well in social situations.						
6. I do well in school and/or work.						
7. My housing situation is satisfactory.						
8. My symptoms are not bothering me.						

[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 consumer. Select only one.]

 Owned or rented house, apartment, trailer, room

 Someone else’s house, apartment, trailer, room

 Homeless (shelter, street/outdoors, park)

 Group home

 Adult foster care

 Transitional living facility

 Halfway house

 Residential Treatment Center

 Hospital (Medical)

 Hospital (Psychiatric)

 Correctional facility (Jail/Prison)

 Nursing Home

 VA Hospital

 Veteran’s home

 Military base

 Other Housed (Specify) _______________________________________________

 Refused

 Don’t Know

D. EDUCATION AND EMPLOYMENT

1. Are you currently enrolled in school or a job training program?

[If enrolled] Is that full time or part time?

Not enrolled

Enrolled, full time

Enrolled, part time

Other (specify)______________

 Refused

 Don’t Know

2. What is the highest level of education you have finished, whether or not you received a degree?

• Less than 12^TH Grade

• 12^TH Grade/High school diploma/Equivalent (GED)

• Voc/Tech diploma

• Some college or university

• Bachelor’s degree (BA, BS)

• Graduate work/Graduate degree

• Refused

• Don’t Know

D. EDUCATION AND EMPLOYMENT (Continued)

3. Are you currently employed?

[Clarify by focusing on status during most of the previous week, determining whether consumer worked at all or had a regular job but was off work.]

• Employed full time (35+ hours per week, or would have been)

• Employed part time

 Unemployed, looking for work

 Unemployed, disabled

 Unemployed, volunteer work

 Unemployed, retired

 Unemployed, not looking for work

 Other (Specify) ___________

 Refused

• Don’t Know

3a. [If employed], Is your employment competitive or supported?

 Competitive employment

 Supported employment

 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 caretaker]

STATEMENT	RESPONSE OPTIONS
	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree	Refused
1. Staff here believe that I can grow, change and recover.						
2. I felt free to complain.						
3. I was given information about my rights.						
4. Staff encouraged me to take responsibility for how I live my life.						
5. Staff told me what side effects to watch out for.						
6. Staff respected my wishes about who is and who is not to be given information about my treatment.						
7. Staff were sensitive to my cultural background (race, religion, language, etc.)						
8. Staff helped me obtain the information I needed so that I could take charge of managing my illness.						
9. I was encouraged to use consumer run programs (support groups, drop-in centers, crisis phone line, etc.)						
10. I felt comfortable asking questions about my treatment and medication.						
11. I, not staff, decided my treatment goals.						
12. I like the services I received here.						
13. If I had other choices, I would still get services from this agency.						
14. I would recommend this agency to a friend or family member.						

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 caretaker]

STATEMENT	RESPONSE OPTIONS
	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree	Refused
1. I am happy with the friendships I have.						
2. I have people with whom I can do enjoyable things.						
3. I feel I belong in my community.						
4. In a crisis, I would have the support I need from family or friends.						

[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 

2