Form Client Interview_B Client Interview_B Client Interview_Baseline

Attachment 2: CSAT GBHI Client Interview - Baseline

OMB No. 0930-xxxx

Expiration Date xx/xx/xx

Center for Substance Abuse Treatment (CSAT) Grants for the Benefit of Homeless Individuals (GBHI), Treatment for Homeless,

Cross-Site Evaluation

Client Interview: BASELINE

Today’s Date: |___|___||___|___||___|___|
MO DAY YR

CSAT GBHI Site Number |___|___|___|___|

CSAT GBHI GPRA Client ID |___|___|___|___|

Interviewer ID |___|___|___|___|

___________________________________________________

Public Burden Statement: 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 OMB control number for this project is 0930-xxxx.  Public reporting burden for this collection of information is estimated to average 20 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Military Service

M1. Did you serve in the US Armed Forces?	1. YES 0. NO (SKIP TO Next Section) 77. DK 99. REFUSED
M2. In what branch(es) of the US Armed Forces did you serve? Please indicate all that apply:	1. Army (include Army National Guard/ Reserve) 2. Navy (include Reserve) 3. Marine Corps (include Reserve) 4. Air Force (include Air Nat’l Guard/Reserve) 5. Coast Guard (include Reserve) 6. Other (Specify: ____________________) 77. DK 99. REFUSED
M3a. When did you enter the Armed Forces? Please provide year. M3b. And when were you discharged from the Armed Forces? Please provide year. (if client needs assistance can prompt for service era)	___ ___ ___ ___ (Year Entered) ___ ___ ___ ___ (Year Discharged)
M4. Have you ever served in a combat theater/zone?	1. YES 0. NO 77. DK 99. REFUSED

Employment

E1. How many days, weeks, or months, have you been employed (on or off the books) in the past 6 months, that is since [DATE]. Please include both part-time and full-time work.

_______ (DAYS) _______ (WEEKS) _______ (MONTHS) 77. DK 88. NA 99. RF

HOMELESSNESS AND HOUSING

H1. Have you ever been homeless (By homeless we mean living on the street, park, abandoned building, in a car or a homeless shelter. Please do not include couch surfing or staying with family or friends.)?

1. _____Yes 0. _____No (If no, skip to QH5)

H2. If yes, how old were you the first time you became homeless? _____Yrs old

H3. During the past 3 years, how many times have you been homeless (By homeless we mean living on the street, park, abandoned building, in a car or a homeless shelter. Please do not include couch surfing or staying with family or friends.)? For instance, if you were on the street, then stayed with family and friends and then went to a shelter that would be two times homeless.

_____Times _____Not homeless in last 3 years

H3a. If homeless during the last 3 years, about how many days, weeks or months were you homeless?

_____days _____weeks or _____months

[If client cannot answer H3a, then interviewer please use categories to probe and help client select category]

1. LESS THAN A MONTH

2. 1 MONTH TO < 6 MONTHS

3. 6 MONTHS TO < 1 YEAR

4. 1 YEAR TO < 2 YEARS

5. 2 YEARS TO < 3 YEARS

6. ALL 3 YEARS

H4. During the past 6 months (beginning around [DATE], how many times have you been homeless (By homeless we mean living on the street, park, abandoned building, in a car or a homeless shelter. Please do not include couch surfing or staying with family or friends.))?

_____Times _____Not homeless last 6 months

H4a. If you were homeless during the last 6 months, about how many days, weeks or months were you homeless?

_____days _____weeks or _____months

[If client cannot answer H4a then interviewer please use categories to probe and help client select category Use categories to probe and help client determine approximate time]

1. LESS THAN A WEEK

2. 1 WEEK TO < 1 MONTH

3. 1 MONTHS TO < 3 MONTHS

4. 3 MONTHS TO < 6 MONTHS

5. ALL SIX MONTHS

H5. Where are you living right now?

01. Your own apartment, house or room (not a hotel/motel) 02. A friend or relative’s apartment, house or room 03. A permanent housing program 04. A transitional housing program 05. A community residence or group home 06. A psychiatric hospital or psychiatric unit 07. Some other type of hospital 08. A residential substance abuse treatment or detoxification program A homeless or family shelter or mission A domestic violence shelter

11. A crisis or respite program 12. On the street or some other place like an abandoned building, a park, or a car 13. A hotel or motel 14. Jail or Prison 15. A college dorm 16. Any other place that hasn’t been mentioned 77. DK 88. NA 99. REFUSED

H6. How many days, weeks or months have you lived there?

_____days _____weeks _____months

H7. We’d like to know all the places you lived in during the past six months. I am going to read a list of places and I would like you to tell me if you spent any time in each place, even if only for one night between [TODAY’S DATE] and [INSERT DATE]. [READ TYPES of LIVING SITUATIONS AND MARK “YES” OR “NO” FOR EACH ITEM]
	Living Situation		Yes	No
A	Your own apartment, house or room (not part of transitional or crisis program or hotel/ motel)		1	0
B	A friend or relative’s apartment, house or room		1	0
C	A permanent housing program with services to help you keep your housing (services either on-site or they come to you)		1	0
D	A transitional housing program		1	0
E	A hotel or motel		1	0
F	A community residence or group home		1	0
G	A residential drug or alcohol treatment program		1	0
H	Jail or Prison		1	0
I	A psychiatric hospital or unit		1	0
J	Some other type of hospital		1	0
K	A domestic violence shelter		1	0
L	A Homeless or family shelter or mission		1	0
M	On the street, in a car, in a park, or abandoned building		1	0
N	A college dorm		1	0
O	Another place I did not mention (Specify: )		1	0

H8. Did you have any problems finding a place to live during the last 6 months? 1. _____Yes 0. _____No (If NO, skip to next section)
H9. If yes, what types of problems did you have finding a place to live in the past 6-months? [READ RESPONSES AND MARK “YES” OR “NO” FOR ALL THAT APPLY.]
		Yes	No
A	Finding a place I could afford	1	0
B	Finding a place in a safe neighborhood	1	0
C	Having the rent deposit together	1	0
D	My credit wasn’t good	1	0
E	Problems because of a criminal record	1	0
F	Trouble finding a place big enough for my family	1	0
G	Finding a place near transportation	1	0
H	Need to complete treatment before I can get housing.	1	0
I	Discrimination, Specify:	1	0
J	Other Problem, specify:	1	0

H10. Now, I will ask you about how you feel about where you live now. After I read each item, please let me know how satisfied you are with your housing. You may use this card (HAND RESPONDENT SHOW CARD #1) to indicate your responses.

Statement	Very Dissatisfied	Dissatisfied	Neither Satisfied Nor Dissatisfied	Satisfied	Very Satisfied	DK	NA	RF
H10a. The amount of choice you have over where you live	1	2	3	4	5	77	88	99
H10b. The safety of your neighborhood	1	2	3	4	5	77	88	99
H10c. The amount of privacy you have	1	2	3	4	5	77	88	99
H10d. How affordable your place is	1	2	3	4	5	77	88	99
H10e. The condition or state of repair of your place	1	2	3	4	5	77	88	99
H10f. The safety and security of where you live	1	2	3	4	5	77	88	99
H10g. The opportunities you have to socialize in the place where you live	1	2	3	4	5	77	88	99
H10h. Overall, how satisfied do you feel about living here?	1	2	3	4	5	77	88	99

H11. The following questions refer to where you live now, your current housing situation. Please indicate with a ‘Yes’ or ‘No’ if you were told the following about your housing.

You may use this card (HAND RESPONDENT SHOW CARD #2) to indicate your responses.
H11a. Did someone tell you that you must stay in mental health treatment to continue living in your current housing?	88. Not receiving mental health treatment 1. YES 0. NO 77. DK 99. REFUSED
You may use this card (HAND RESPONDENT SHOW CARD #3) to indicate your responses.
H11b. Did someone tell you that you must stay in alcohol or drug treatment to continue living in your current housing?	88. Not receiving alcohol or drug treatment 1. YES 0. NO 77. DK 99. REFUSED

The following statements are about the requirements that may be a part of your housing. Please indicate how much you ‘agree’ or ‘disagree’ with each statement. You may use this card (HAND RESPONDENT SHOW CARD #4) to indicate your responses.

Statement	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree	DK	NA	RF
H11c. You must stay in mental health treatment to continue living in your current housing	1	2	3	4	5	77	88	99
H11d. You must stay in drug or alcohol treatment to continue living in your current housing.	1	2	3	4	5	77	88	99
H11e. You would be allowed to stay in the place where you currently live if you discontinued mental health services.	1	2	3	4	5	77	88	99
H11f. You would be allowed to stay in the place where you currently live if you broke program rules about alcohol or drug use.	1	2	3	4	5	77	88	99

criminal justice

Have you ever been arrested, booked, or taken into custody in the past?	1. YES 0. NO (If NO, skip to next section) 77. DK 99. RF
How many times have you been arrested, booked, or taken into custody in the past 6 months, that is since [DATE]?	_________# times 77. DK 88. NA 99. RF
How many nights did you spend in a holding cell, jail, or prison in the past 6 months, that is since [DATE]?	_________ # Nights 77. DK 88. NA 99. RF

TREATMENT HISTORY, Needs and Services

Have you ever been diagnosed with or treated for alcohol abuse or dependence?	1. YES 0. NO 77. DK 99. RF
Have you ever been diagnosed with or treated for drug abuse or dependence?	1. YES 0. NO 77. DK 99. RF
Have you ever been diagnosed with or treated for schizophrenia, major depression, or bipolar disorder (mania)?	1. YES 0. NO 77. DK 99. RF
Have you ever been diagnosed with or treated for anxiety disorder (e.g. general, social, panic), phobia or obsessive compulsive disorder?	1. YES 0. NO 77. DK 99. RF
Have you ever been diagnosed with or treated for post-traumatic stress disorder?	1. YES 0. NO 77. DK 99. RF
Have you ever been diagnosed with or treated for ADHD, Conduct Disorder, a personality disorder (e.g. Borderline, Antisocial, Narcissistic, etc)?	1. YES 0. NO 77. DK 99. RF

RTC1. Have you drank any alcohol in the past 6 months?

1. YES

0. NO [If NO skip to RTC2, next set of questions]

77. DK

99. RF

The following statements describe how a person might feel about their alcohol use. Please indicate the extent to which you tend to agree or disagree with each statement. In each case, make your choice in terms of how you feel right now, not what you have felt in the past or would like to feel. You may use this card (HAND RESPONDENT SHOW CARD #4) to indicate your responses.

Statement	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree	DK	NA	RF
RTC1a. I don’t think I drink too much.	1	2	3	4	5	77	88	99
RTC1b. I am trying to drink less than I used to.	1	2	3	4	5	77	88	99
RTC1c. I enjoy my drinking, but sometimes I drink too much.	1	2	3	4	5	77	88	99
RTC1d. Sometimes I think I should cut down on my drinking.	1	2	3	4	5	77	88	99
RTC1e. It’s a waste of time thinking about my drinking.	1	2	3	4	5	77	88	99
RTC1f. I have recently changed my drinking habits.	1	2	3	4	5	77	88	99
RTC1g. Anyone can talk about wanting to do something about drinking, but I am actually doing something about it.	1	2	3	4	5	77	88	99
RTC1h. I am at the stage where I should think about drinking less alcohol	1	2	3	4	5	77	88	99
RTC1i. My drinking is a problem sometimes.	1	2	3	4	5	77	88	99
RTC1j. There is no need for me to think about changing my drinking.	1	2	3	4	5	77	88	99
RTC1k. I am actually changing my drinking habits right now.	1	2	3	4	5	77	88	99
RTC1l. Drinking less alcohol would be pointless for me.	1	2	3	4	5	77	88	99

RTC2. Have you used any illegal drugs in the past 6 months?

1. YES

0. NO [If NO, skip to next set of questions and go to PCL1]]

77. DK

99. RF

The following statements describe how a person might feel about their drug use. Please indicate the extent to which you tend to agree or disagree with each statement. In each case, make your choice in terms of how you feel right now, not what you have felt in the past or would like to feel. You may use this card (HAND RESPONDENT SHOW CARD #4) to indicate your responses.

Statement	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree	DK	NA	RF
RTC2a. I don’t think I use drugs too much.	1	2	3	4	5	77	88	99
RTC2b. I am trying to use drugs less than I used to.	1	2	3	4	5	77	88	99
RTC2c. I enjoy using drugs, but sometimes I use too much.	1	2	3	4	5	77	88	99
RTC2d. Sometimes I think I should cut down on my drug use.	1	2	3	4	5	77	88	99
RTC2e. It’s a waste of time thinking about my drug use.	1	2	3	4	5	77	88	99
RTC2f. I have recently changed my drug habits.	1	2	3	4	5	77	88	99
RTC2g. Anyone can talk about wanting to do something about their drug use, but I am actually doing something about it.	1	2	3	4	5	77	88	99
RTC2h. I am at the stage where I should think about using less drugs.	1	2	3	4	5	77	88	99
RTC2i. My drug use is a problem sometimes.	1	2	3	4	5	77	88	99
RTC2j. There is no need for me to think about changing my drug use.	1	2	3	4	5	77	88	99
RTC2k. I am actually changing my drug habits right now.	1	2	3	4	5	77	88	99
RTC2l. Using less drugs would be pointless for me.	1	2	3	4	5	77	88	99

PCL1. Now, I’m going to read a list of problems and complaints people sometimes have in response to stressful life experiences. For each item, please tell me how much you’ve been bothered by that problem in the past 30 days (e.g., the past month). You may use this card (HAND RESPONDENT SHOW CARD #5) to indicate your responses.

In the past month how much have you been bothered by…	Not at all	Somewhat	Moderately	Considerably	Extremely	DK	NA	RF
PCL1a, Repeated disturbing memories, thoughts, or images of a stressful experience from the past?	1	2	3	4	5	77	88	99
PCL1b. Feeling very upset when something reminded you of a stressful experience from the past?	1	2	3	4	5	77	88	99
PCL1c. Avoiding activities or situations because they reminded you of a stressful experience from the past?	1	2	3	4	5	77	88	99
PCL1d. Feeling distant or cut off from other people?	1	2	3	4	5	77	88	99
PCL1e. Feeling irritable or having angry outbursts?	1	2	3	4	5	77	88	99
PCL1f. Having difficulty concentrating?	1	2	3	4	5	77	88	99

SV. Now I am going to ask you about services you may have needed and/or received in the last 6 months, that is, since ___/___/___. Please indicate with a ‘yes’ or ‘no’ if you have needed any of the following services, and then if you have received the following services.

	YES	NO	DK	NA	RF
a. Did you need any outpatient substance abuse treatment services, such as substance abuse education, or individual or group counseling (do not include case management services)?	1	0	77	88	99
b. Did you receive any outpatient substance abuse services? <If no, skip to SV2>	1	0	77	88	99
c. How many days did you receive these outpatient services in the past 6 months, that is since [DATE].	___ ___ ____ days			88	99
a. Did you need treatment in a detoxification program where you stayed overnight?	YES	NO	DK	NA	RF
	1	0	77	88	99
b. Did you receive any treatment in a residential or inpatient detoxification program? <If no, skip to SV3>	1	0	77	88	99
c. How many nights did you stay in a detoxification program in the past 6 months, that is since [DATE].	___ ___ ____ nights			88	99
a. Did you need residential treatment in a substance abuse program where you stayed overnight (other than detoxification)?	YES	NO	DK	NA	RF
	1	0	77	88	99
b. Did you receive any residential treatment in a substance abuse program? <If no, skip to SV4>	1	0	77	88	99
c. How many nights or days did you spend in a residential treatment substance abuse program in the past 6 months, that is since [DATE].	___ ___ ____ nights/days			88	99
a. Did you need any methadone services?	YES	NO	DK	NA	RF
	1	0	77	88	99
b. Did you receive any methadone services?	1	0	77	88	99
a. Did you need outpatient mental health treatment, such as individual, family, group therapy, day treatment, or other outpatient treatment? (do not include case management services)	1	0	77	88	99
b. Did you receive any outpatient mental health treatment, such as individual, family, group therapy, day treatment, or other outpatient treatment? (do not include case management services) <If no, skip to SV6>	1	0	77	88	99
c. How many days did you receive these mental health services in the past 6 months, that is since [DATE].	___ ___ ____ days			88	99
a. Did you need any trauma-specific treatment; that is, groups or services to address traumatic experiences?	1	0	77	88	99
b. Did you receive any trauma-specific treatment? (e.g., TREM (Trauma Recovery Empowerment Motivation) groups, Seeking Safety groups, etc.)?	1	0	77	88	99
a. Did you need to see a doctor or nurse about psychiatric medications that you are taking or planning to take?	1	0	77	88	99
b. Did you receive the services of a doctor or nurse for psychiatric medications that you are taking or planning to take?	1	0	77	88	99
a. Did you need the services of a case manager or some other person to help you coordinate services or participate in treatment?	1	0	77	88	99
b. Did you receive any case management services?	1	0	77	88	99
a. Did you need any vocational or rehabilitation services, such as supported employment, vocational counseling, clubhouse program or supported education? (see glossary for definitions)	1	0	77	88	99
Did you receive any vocational or rehabilitation services?	1	0	77	88	99
a. Did you need any help with housing services; for example, help finding shelter or housing, dealing with a landlord or eviction, help getting a housing subsidy?	1	0	77	88	99
b. Did you receive any help with housing services?	1	0	77	88	99
a. Did you need any help with transportation to meet basic needs; for example, help getting to work or appointments?	1	0	77	88	99
b. Did you receive any help with transportation?	1	0	77	88	99
a. Did you need/want to participate in any self-help or peer support services? Self-help and peer support refers to activities led by people with substance abuse or mental health/psychiatric problems to share their strengths and help each other cope and grow. It does not include support groups led by service providers who are not peers.	1	0	77	88	99
b. Did you participate in any self-help or peer support services?	1	0	77	88	99
a. Did you need any childcare services; that is, help finding childcare or obtaining a subsidy or other financial support for childcare?	1	0	77	88	99
b. Did you receive any childcare services?	1	0	77	88	99
a. Did you need any other services that were not mentioned?	1	0	77	88	99
b. If yes, Specify: ______________________
c. Did you receive these services?	1	0	77	88	99

CSAT GBHI Cross-Site Evaluation

Client Interview Part II for Self-Completion — Baseline:

Perception of Care

[Note two sheets with 16 questions are separately provided to the participant by the GPRA interviewer to be completed on their own, put into a provided envelope and sealed—see Client Informed Consent Script]

Today’s Date: |___|___||___|___||___|___|
MO DAY YR

CSAT GBHI Site Number |___|___|___|___|

CSAT GBHI GPRA Client ID |___|___|___|___|

Thank you for taking the time to complete these questions.

Please complete the following 16 questions and when you are done, please put them in the envelope you were given, seal it and give it to the GPRA interviewer.

PC. In order to provide the best possible services, we need to know what you think about the services you received during the past 30 days, the people who provided it, and the results. Please indicate your disagreement/agreement with each of the following statements.

Statement	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree	DK	NA	RF
PC1. I feel free to complain.	1	2	3	4	5	77	88	99
PC2. I was given information about my rights.	1	2	3	4	5	77	88	99
PC3. Staff told me what side effects to watch out for.	1	2	3	4	5	77	88	99
PC4. Staff were sensitive to my cultural background (race, religion, language, etc).	1	2	3	4	5	77	88	99
PC5. I felt comfortable asking questions about my treatment and medication.	1	2	3	4	5	77	88	99
PC6. I, not staff, decided my treatment goals.	1	2	3	4	5	77	88	99
PC7. If I had other choices, I would get services from this agency.	1	2	3	4	5	77	88	99

TCC. The following questions are about what you may have been told about participating in services. Please indicate with a ‘Yes’ or ‘No’ if you were told the following about participating in your treatment program.

Were you told that if you do not participate in your program, you would lose your income benefits? Benefits like, TANF/DSS, Medicaid, Social Security Insurance (SSI), Social Security Disability Insurance (SSDI), or any other benefits for which you receive money	1. YES 0. NO 3. Do not have benefits 77. DK 99. RF
Were you told that if you do not participate in your program, you would lose your housing benefits? Housing benefits like Section 8, a housing subsidy, or any other type of housing voucher	1. YES 0. NO 3. Do not have housing benefits 77. DK 99. RF
Were you told if you do not participate in your program, you would lose custody of your children?	1. YES 0. NO 3. Do not have children 77. DK 99. RF
Are you court-ordered to participate in your program?	1. YES 0. NO 77. DK 99. RF
If you are taking any medications for mental health problems- were you told that you would have to stop taking these medications to get substance abuse treatment?	1. YES 0. NO 3. Not taking medications 77. DK 99. RF
If you are currently in substance abuse treatment- were you told that you needed to be “clean and sober” to get mental health treatment?	1. YES 0. NO 3. Not in substance abuse treatment 77. DK 99. RF
If you are currently in substance abuse treatment- were you told that you needed to be “clean and sober” to get substance abuse treatment?	1. YES 0. NO 3. Not in substance abuse treatment 77. DK 99. RF
Where you told you had to stay in substance abuse or mental health treatment to get housing or stay in housing?	1. YES 0. NO 3. Not in treatment 77. DK 99. RF
If you wanted to, could you switch to another program that provides the same types of services you receive from here?	1. YES 0. NO 77. DK 99. RF

1