Form GPRA Client Outcom GPRA Client Outcom GPRA Client Outcome Instrument

Form Approved

OMB No. 0930-0208

Expiration Date XX/XX/XXXX

CSAT GPRA Client Outcome

Measures for Discretionary Programs

(Revised xx/xx/2010)

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information, 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 7-1044, 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 0930-0208.

A. RECORD MANAGEMENT

Client ID |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|

Client Type:

• Treatment client

• Client in recovery

Contract/Grant ID |____|____|____|____|____|____|____|____|____|____|

Interview Type [CIRCLE ONLY ONE TYPE.]

Intake [GO TO INTERVIEW DATE]

6 month follow-up → → → Did you conduct a follow-up interview? � Yes  � No

[IF NO, GO DIRECTLY TO SECTION I.]

3 month follow-up [ADOLESCENT PORTFOLIO ONLY] →  

Did you conduct a follow-up interview? � Yes  � No [IF NO, GO DIRECTLY TO SECTION I.]

Discharge → → → Did you conduct a discharge interview? � Yes  � No

[IF NO, GO DIRECTLY TO SECTION J.]

Interview Date |____|____| / |____|____| / |____|____|____|____|

Month Day Year

[FOLLOW-UP AND DISCHARGE INTERVIEWS: SKIP TO SECTION B.]

1. Was the client screened by your program for co-occurring mental health and substance use disorders?

� Yes

� No [SKIP 1a.]

1a. [IF YES] Did the client screen positive for co-occurring mental health and substance use

disorders?

� Yes

� No

sbirt/CAMPUS SBI continue. all others go to section a “planned services.”

__________________________________________________________________________________________

THIS SECTION FOR THE FOLLOWING GRANTS ONLY [REPORTED ONLY AT INTAKE/BASELINE]:

SBIRT (Items 2, 2a, & 3), CAMPUS SBI (Items 2 & 2a)

2. How did the client screen for your SBIRT or Campus SBI?

  � Negative

 � Positive

2a. What was his/her screening score? AUDIT = |____|____|

CAGE = |____|____|

DAST = |____|____|

DAST-10 = |____|____|

NIAAAGuide = |____|____|

ASSIST/Alcohol Subscore = |____|____|

Other (Specify) _____________ = |____|____|

______________________________________

______________________________________

______________________________________

Campus SBI: GO TO SECTION A “PLANNED SERVICES.”

3. Was he/she willing to continue his/her participation in the SBIRT program?

� Yes

� No

A. RECORD MANAGEMENT - PLANNED SERVICES [REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT INTAKE/BASELINE]

Identify the services you plan to provide to the client during the client’s course of treatment/recovery. [CIRCLE ‘Y’ FOR YES OR ‘N’ FOR NO FOR EACH ONE.]

Modality Yes No

[SELECT AT LEAST ONE MODALITY.]

1. Case Management Y N

2. Day Treatment Y N

3. Inpatient/Hospital (Other Than Detox) Y N

4. Outpatient Y N

5. Outreach Y N

6. Intensive Outpatient Y N

7. Methadone Y N

8. Residential/Rehabilitation Y N

9. Detoxification (Select Only One)

A. Hospital Inpatient Y N

B. Free Standing Residential Y N

C. Ambulatory Detoxification Y N

10. After Care Y N

11. Recovery Support Y N

12. Other (Specify) Y N

[SELECT AT LEAST ONE SERVICE.]

Treatment Services Yes No

[SBIRT GRANTS: You must circle ‘Y’ for at least one of the Treatment Services numbered 1 through 4.]

1. Screening Y N

2. Brief Intervention Y N

3. Brief Treatment Y N

4. Referral to Treatment Y N

5. Assessment Y N

6. Treatment/Recovery Planning Y N

7. Individual Counseling Y N

8. Group Counseling Y N

9. Family/Marriage Counseling Y N

10. Co-Occurring Treatment/

‌Recovery Services Y N

11. Pharmacological Interventions Y N

12. HIV/AIDS Counseling Y N

13. Other Clinical Services Y N

(Specify)

Case Management Services Yes No

1. Family Services (Including Marriage Education, Parenting, Child Development Services) Y N

2. Child Care Y N

3. Employment Service

A. Pre-Employment Y N

B. Employment Coaching Y N

4. Individual Services Coordination Y N

5. Transportation Y N

6. HIV/AIDS Service Y N

7. Supportive Transitional Drug-Free Housing Services Y N

8. Other Case Management Services Y N

(Specify)

Medical Services Yes No

1. Medical Care Y N

2. Alcohol/Drug Testing Y N

3. HIV/AIDS Medical Support & Testing Y N

4. Other Medical Services Y N

(Specify)

After Care Services Yes No

1. Continuing Care Y N

2. Relapse Prevention Y N

3. Recovery Coaching Y N

4. Self-Help and Support Groups Y N

5. Spiritual Support Y N

6. Other After Care Services Y N

(Specify)

Education Services Yes No

1. Substance Abuse Education Y N

2. HIV/AIDS Education Y N

3. Other Education Services Y N

(Specify)

Peer-To-Peer Recovery Support Services Yes No

1. Peer Coaching or Mentoring Y N

2. Housing Support Y N

3. Alcohol- and Drug-Free Social Activities Y N

4. Information and Referral Y N

5. Other Peer-to-Peer Recovery Support Services Y N

(Specify)

A. RECORD MANAGEMENT - DEMOGRAPHICS [ASKED ONLY AT INTAKE/BASELINE]

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 Y N REFUSED

Cuban Y N REFUSED

Dominican Y N REFUSED

Mexican Y N REFUSED

Puerto Rican Y N REFUSED

South American Y N REFUSED

Other Y N REFUSED [IF YES, SPECIFY BELOW]

(Specify)

3. What is your race? 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 Y N REFUSED

Asian Y N REFUSED

Native Hawaiian or other Pacific Islander Y N REFUSED

Alaska Native Y N REFUSED

White Y N REFUSED

American Indian Y N REFUSED

4. What is your date of birth?*

|____|____| / |____|____| / [*THE SYSTEM WILL ONLY SAVE MONTH AND YEAR.

Month Day TO MAINTAIN CONFIDENTIALITY DAY IS NOT SAVED.]

|____|____|____|____|

Year

 Refused

B. DRUG AND ALCOHOL USE

In Section B, ORP and EADCSCT grantees to use the 90 days prior to incarceration for all intake interviews and 90 days prior for follow-up and discharge interviews.

	Number of Days REFUSED	DON’T KNOW
1. During the past 30 days how many days have you used the following:
a. Any alcohol [IF ZERO, SKIP TO ITEM B1c.]	|____|____| �	�
b1. Alcohol to intoxication (5+ drinks in one sitting)	|____|____| �	�
b2. Alcohol to intoxication (4 or fewer drinks in one sitting and felt high)	|____|____| �	�
c. Illegal drugs [IF B1a OR B1c = 0, RF, DK, THEN SKIP TO ITEM B2.]	|____|____| �	�
d. Both alcohol and drugs (on the same day)	|____|____| �	�
Route of Administration Types: 1. Oral 2. Nasal 3. Smoking 4. Non-IV injection 5. IV *Note the usual route. For more than one route, choose the most severe. The routes are listed from least severe (1) to most severe (5).	Number of Days RF DK	Route* RF DK
2. During the past 30 days, how many days have you used any of the following: [IF THE VALUE IN ANY ITEM B2a THROUGH B2i > 0, THEN THE VALUE IN B1c MUST BE > 0.]
a. Cocaine/Crack	|____|____| � �	|____| � �
b. Marijuana/Hashish (Pot, Joints, Blunts, Chronic, Weed, Mary Jane)	|____|____| � �	|____| � �
c. Opiates:
1. Heroin (Smack, H, Junk, Skag)	|____|____| � �	|____| � �
2. Morphine	|____|____| � �	|____| � �
3. Diluadid	|____|____| � �	|____| � �
4. Demerol	|____|____| � �	|____| � �
5. Percocet	|____|____| � �	|____| � �
6. Darvon	|____|____| � �	|____| � �
7. Codeine	|____|____| � �	|____| � �
8. Tylenol 2,3,4	|____|____| � �	|____| � �
9. Oxycontin/Oxycodone	|____|____| � �	|____| � �
d. Non-prescription methadone	|____|____| � �	|____| � �
e. Hallucinogens/psychedelics, PCP (Angel Dust, Ozone, Wack, Rocket Fuel) MDMA (Ecstasy, XTC, X, Adam), LSD (Acid, Boomers, Yellow Sunshine), Mushrooms or Mescaline	|____|____| � �	|____| � �
f. Methamphetamine or other amphetamines (Meth, Uppers, Speed, Ice, Chalk, Crystal, Glass, Fire, Crank)	|____|____| � �	|____| � �

B. DRUG AND ALCOHOL USE (Continued)

Route of Administration Types: 1. Oral 2. Nasal 3. Smoking 4. Non-IV injection 5. IV *Note the usual route. For more than one route, choose the most severe. The routes are listed from least severe (1) to most severe (5).
2. During the past 30 days, how many days have you used any of the following: [IF THE VALUE IN ANY ITEM B2a THROUGH B2i > 0, THEN THE VALUE IN B1c MUST BE > 0.]	Number of Days RF DK	Route* RF DK
g. 1. Benzodiazepines: Diazepam (Valium); Alprazolam (Xanax); Triazolam (Halcion); and Estasolam (Prosom and Rohypnol–also known as roofies, roche, and cope)	|____|____| � �	|____| � �
2. Barbiturates: Mephobarbital (Mebacut); and pentobarbital sodium (Nembutal)	|____|____| � �	|____| � �
3. Non-prescription GHB (known as Grievous Bodily Harm; Liquid Ecstasy; and Georgia Home Boy)	|____|____| � �	|____| � �
4. Ketamine (known as Special K or Vitamin K)	|____|____| � �	|____| � �
5. Other tranquilizers, downers, sedatives or hypnotics	|____|____| � �	|____| � �
h. Inhalants (poppers, snappers, rush, whippets)	|____|____| � �	|____| � �
i. Other illegal drugs (Specify)	|____|____| � �	|____| � �

3. In the past 30 days have you injected drugs? [IF ANY ROUTE OF ADMINISTRATION IN B2a THROUGH B2i = 4 or 5, THEN B3 MUST = YES.]

� YES

� NO

� Refused

� Don’t know

[IF NO, REFUSED, OR DON’T KNOW SKIP TO SECTION C.]

4. In the past 30 days, how often did you use a syringe/needle, cooker, cotton or water that someone else used?

� Always

� More than half the time

� Half the time

� Less than half the time

� Never

� Refused

� Don’t know

C. FAMILY AND LIVING CONDITIONS

1. In the past 30 days, where have you been living most of the time? [DO NOT READ RESPONSE OPTIONS TO CLIENT.]

� Shelter (safe havens, transitional living center [TLC], low demand facilities, reception centers, other temporary day or evening facility)

� Street/outdoors (sidewalk, doorway, park, public or abandoned building)

� Institution (hospital, nursing home, jail/prison)

� Housed: [if housed, check appropriate subcategory:]

� Own/rent apartment, room, or house

� Someone else’s apartment, room or house

� DORMITORY/COLLEGE RESIDENCE

� Halfway house

� Residential treatment

� Other housed (Specify)

� Refused

� Don’t know

2. During the past 30 days, how stressful have things been for you because of your use of alcohol or other drugs? [IF B1a OR B1c > 0, THEN C2 CANNOT = “ NOT APPLICABLE”.]

� Not at all

� Somewhat

� Considerably

� Extremely

� Not Applicable [use ONLY IF b1a and b1c = 0.]

� Refused

� Don’t know

3. During the past 30 days, has your use of alcohol or other drugs caused you to reduce or give up important activities? [IF B1a OR B1c > 0, THEN C3 CANNOT = “ NOT APPLICABLE”.]

� Not at all

� Somewhat

� Considerably

� Extremely

� Not Applicable [use ONLY IF b1a and b1c = 0.]

� Refused

� Don’t know

C. FAMILY AND LIVING CONDITIONS (Continued)

4. During the past 30 days, has your use of alcohol or other drugs caused you to have emotional problems? [IF B1a OR B1c > 0, THEN C4 CANNOT = “ NOT APPLICABLE”.]

� Not at all

� Somewhat

� Considerably

� Extremely

� Not Applicable [use ONLY IF b1a and b1c = 0.]

� Refused

� Don’t know

5. [IF NOT MALE,] Are you currently pregnant?

� Yes

� No

� Refused

� Don’t know

6. Do you have children?

� Yes

� No

� Refused

� Don’t know

[IF NO, REFUSED, OR DON’T KNOW SKIP TO SECTION D.]

a. How many children do you have? [IF C6 = YES, THEN A VALUE IN C6a MUST BE > 0.]

|____|____|  � Refused  � Don’t know

b. Are any of your children living with someone else due to a child protection court order?

� Yes

� No

� Refused

� Don’t know

[IF NO, REFUSED, OR DON’T KNOW SKIP TO ITEM C6d.]

c. [IF YES,] How many of your children are living with someone else due to a child protection court order? [THE VALUE IN C6c CANNOT EXCEED THE VALUE IN C6a.]

|____|____|  � Refused  � Don’t know

C. FAMILY AND LIVING CONDITIONS (Continued)

d. For how many of your children have you lost parental rights? [THE CLIENT’S PARENTAL RIGHTS WERE TERMINATED.][THE VALUE IN ITEM C6d CANNOT EXCEED THE VALUE IN C6a.]

|____|____|  � Refused  � Don’t know

D. EDUCATION, EMPLOYMENT, AND INCOME

1. Are you currently enrolled in school or a job training program? [IF ENROLLED,] Is that full time or part time? [IF CLIENT IS INCARCERATED CODE D1 AS “NOT ENROLLED.”]

� 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?

 NEVER ATTENDED

 1^ST GRADE

 2^ND GRADE

 3^RD GRADE

 4^TH GRADE

 5^TH GRADE

 6^TH GRADE

• 7^TH GRADE

• 8^TH GRADE

• 9^TH GRADE

• 10^TH GRADE

• 11^TH GRADE

• 12^TH GRADE/HIGH SCHOOL DIPLOMA/EQUIVALENT

• COLLEGE OR UNIVERSITY/1^st YEAR COMPLETED

• COLLEGE OR UNIVERSITY/2^nd YEAR COMPLETED/ASSOCIATES DEGREE (AA, AS)

• COLLEGE OR UNIVERSITY/3^rd YEAR COMPLETED

• BACHELOR’S DEGREE (BA, BS) OR HIGHER

• VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO VOC/TECH DIPLOMA

• VOC/TECH DIPLOMA AFTER HIGH SCHOOL

 Refused

 Don’t know

D. EDUCATION, EMPLOYMENT, AND INCOME (Continued)

3. Are you currently employed? [CLARIFY BY FOCUSING ON STATUS DURING MOST OF THE PREVIOUS WEEK, DETERMINING WHETHER CLIENT WORKED AT ALL OR HAD A REGULAR JOB BUT WAS OFF WORK. [IF CLIENT IS “ENROLLED, FULL TIME” IN D1 AND INDICATES “EMPLOYED FULL TIME” IN D3, ASK FOR CLARIFICATION. IF CLIENT IS INCARCERATED AND HAS NO WORK OUTSIDE OF JAIL, CODE D3 AS “UNEMPLOYED, NOT LOOKING FOR 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

4. Approximately, how much money did YOU receive (pre-tax individual income) in the past 30 days from… [IF D3 DOES NOT = “EMPLOYED” AND THE VALUE IN D4a IS GREATER THAN ZERO, PROBE. IF D3 = “UNEMPLOYED, LOOKING FOR WORK” AND THE VALUE IN D4b = 0, PROBE. IF D3 = “UNEMPLOYED, RETIRED” AND THE VALUE IN D4c = 0, PROBE. IF D3 = “UNEMPLOYED, DISABLED” AND THE VALUE IN D4d = 0, PROBE.]

RF DK

a. Wages $ |__|__|__| , |__|__|__|   �  � 

b. Public assistance $ |__|__|__| , |__|__|__|   � �

c. Retirement $ |__|__|__| , |__|__|__|   �   � 

d. Disability $ |__|__|__| , |__|__|__|   �   �

e. Non-legal income $ |__|__|__| , |__|__|__|   �   �

f. Family and/or friends $ |__|__|__| , |__|__|__|   �   �

g. Other (Specify) $ |__|__|__| , |__|__|__|   �   � 

E. CRIME AND CRIMINAL JUSTICE STATUS

1. In the past 30 days, how many times have you been arrested?

|____|____| times  � Refused  � Don’t know

[IF NO ARRESTS, SKIP TO ITEM E3.]

2. In the past 30 days, how many times have you been arrested for drug-related offenses? [THE VALUE IN E2 CANNOT BE GREATER THAN THE VALUE IN E1.]

|____|____| times  � Refused  � Don’t know

E. CRIME AND CRIMINAL JUSTICE STATUS (Continued)

3. In the past 30 days, how many nights have you spent in jail/prison? [IF THE VALUE IN E3 IS GREATER THAN 15, THEN C1 MUST = INSTITUTION (JAIL/PRISON). IF C1 = INSTITUTION (JAIL/PRISON), THEN THE VALUE IN E3 MUST BE GREATER THAN OR EQUAL TO 15.]

|____|____| nights  � Refused  � Don’t know

4. In the past 30 days, how many times have you committed a crime? [CHECK NUMBER OF DAYS USED ILLEGAL DRUGS IN ITEM B1c ON PAGE 4. ANSWER HERE IN E4 SHOULD BE EQUAL TO OR GREATER THAN NUMBER IN B1c BECAUSE USING ILLEGAL DRUGS IS A CRIME.]

|____|____|____| times  � Refused  � Don’t know

5. Are you currently awaiting charges, trial, or sentencing?

 Yes

 No

� Refused

� Don’t know

6. Are you currently on parole or probation?

 Yes

 No

� Refused

� Don’t know

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY

1. How would you rate your overall health right now?

� Excellent

� Very good

� Good

� Fair

� Poor

� Refused

� Don’t know

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY (Cont.)

2. During the past 30 days, did you receive:

a. Inpatient Treatment for:		[IF YES]
	YES	Altogether for how many nights	NO	RF	DK
i. Physical complaint	�	nights	�	�	�
ii. Mental or emotional difficulties	�	nights	�	�	�
iii. Alcohol or substance abuse	�	nights	�	�	�

b. Outpatient Treatment for:		[IF YES]
	YES	Altogether for how many times	NO	RF	DK
i. Physical complaint	�	times	�	�	�
ii. Mental or emotional difficulties	�	times	�	�	�
iii. Alcohol or substance abuse	�	times	�	�	�

c. Emergency Room Treatment for:		[IF YES]
	YES	Altogether for how many times	NO	RF	DK
i. Physical complaint	�	times	�	�	�
ii. Mental or emotional difficulties	�	times	�	�	�
iii. Alcohol or substance abuse	�	times	�	�	�

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY (Cont.)

3. During the past 30 days, did you engage in sexual activity?

� Yes

� No → [SKIP TO F4.]

� Not permitted to ask → [SKIP TO F4.]

� Refused → [SKIP TO F4.]

� Don’t know → [SKIP TO F4.]

[IF YES] Altogether, how many:

	Contacts	RF	DK
a. Sexual contacts (vaginal, oral, or anal) did you have?	|____|____|____|		
b. Unprotected sexual contacts did you have? [THE VALUE IN F3b SHOULD NOT BE GREATER THAN THE VALUE IN F3a.] [IF ZERO, SKIP TO F4.]	|____|____|____|		
c. Unprotected sexual contacts were with an individual who is or was: [NONE OF THE VALUES IN F3c1 THROUGH F3c3 CAN BE GREATER THAN THE VALUE IN F3b.]
1. HIV positive or has AIDS	|____|____|____|		
2. An injection drug user	|____|____|____|		
3. High on some substance	|____|____|____|		

4. Have you ever been tested for HIV?

� Yes [GO TO F4a.]

� No [SKIP TO F5.]

� Refused [SKIP TO F5]

� Don’t know [SKIP TO F5.]

4a. Do you know the results of your HIV testing?

� Yes

� No

5. In the past 30 days, not due to your use of alcohol or drugs, how many days have you:

	Days	RF	DK
a. Experienced serious depression	|____|____|		
b. Experienced serious anxiety or tension	|____|____|		
c. Experienced hallucinations	|____|____|		
d. Experienced trouble understanding, concentrating, or remembering	|____|____|		
e. Experienced trouble controlling violent behavior	|____|____|		
f. Attempted suicide	|____|____|		
g. Been prescribed medication for psychological/emotional problem	|____|____|		

[IF CLIENT REPORTS ZERO DAYS, RF OR DK TO ALL ITEMS IN QUESTION 5, SKIP TO SECTION G.]

6. How much have you been bothered by these psychological or emotional problems in the past 30 days?

� NOT AT ALL

� SLIGHTLY

� MODERATELY

� CONSIDERABLY

� EXTREMELY

� Refused

� Don’t know

G. SOCIAL CONNECTEDNESS

1. In the past 30 days, did you attend any voluntary self-help groups for recovery that were not affiliated with a religious or faith-based organization? In other words, did you participate in a non-professional, peer-operated organization that is devoted to helping individuals who have addiction related problems such as: Alcoholics Anonymous, Narcotics Anonymous, Oxford House, Secular Organization for Sobriety, or Women for Sobriety, etc.

� Yes  [IF YES] Specify how many times      Refused   Don’t know

� No

� Refused

� Don’t know

2. In the past 30 days, did you attend any religious/faith affiliated recovery self-help groups?

� Yes  [IF YES] Specify how many times      Refused   Don’t know

� No

� Refused

� Don’t know

3. In the past 30 days, did you attend meetings of organizations that support recovery other than the organizations described above?

� Yes  [IF YES] Specify how many times      Refused   Don’t know

� No

� Refused

� Don’t know

4. In the past 30 days, did you have interaction with family and/or friends that are supportive of your recovery?

� Yes

� No

� Refused

� Don’t know

5. To whom do you turn when you are having trouble? [SELECT ONLY ONE.]

� No One

� Clergy Member

� Family Member

� Friends

� REFUSED

� DoN’T KNOW

� Other Specify: ______________________________

H. VIOLENCE AND TRAUMA

1. Have you ever experienced violence or trauma in any setting (including community or school violence; domestic violence; physical, psychological, or sexual maltreatment/assault within or outside of the family; natural disaster; terrorism; neglect; or traumatic grief?)

� Yes

� No [SKIP TO SECTION I.]

� Refused

� Don’t know

2. Did any of these experiences feel so frightening, horrible, or upsetting that in the past and/or the present that you:

 

2a. Have had nightmares about it or thought about it when you did not want to? 

� Yes

� No

� Refused

� Don’t know

2b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it?

� Yes

� No

� Refused

� Don’t know

2c. Were constantly on guard, watchful, or easily startled?

� Yes

� No

� Refused

� Don’t know

2d. Felt numb and detached from others, activities, or your surroundings?

� Yes

� No

� Refused

� Don’t know

3. In the past 30 days, how often have you been hit, kicked, slapped, or otherwise physically hurt?

NEVER

A FEW TIMES

MORE THAN A FEW TIMES

REFUSED

DON’T KNOW

I. MILITARY FAMILY AND DEPLOYMENT

1. Have you ever served in the Armed Forces, in the Reserves, or in the National Guard? [IF SERVED] What area, the Armed Forces, Reserves or National Guard?

NO [SKIP TO QUESTION I2.]

YES, IN THE ARMED FORCES

YES, IN THE RESERVES

YES, IN THE NATIONAL GUARD

1a   Are you currently on active duty in the Armed Forces, in the Reserves, or in the National Guard [select all that apply]? [IF ACTIVE] What area, the Armed Forces, Reserves or National Guard?

YES, IN THE ARMED FORCES

YES, IN THE RESERVES

YES, IN THE NATIONAL GUARD

NO, SEPARATED OR RETIRED FROM ARMED FORCES, RESERVES, OR NATIONAL GUARD

1b.   Have you ever been deployed to a combat zone?

NEVER DEPLOYED

IRAQ OR AFGHANISTAN (E.G., OEF/QIF/ODN)

PERSIAN GULF (OPERATION DESERT SHIELD/DESERT STORM)

VIETNAM/SOUTHEAST ASIA

KOREA

WWII

DEPLOYED TO A COMBAT ZONE NOT LISTED ABOVE (E.G., BOSNIA/SOMALIA)

2.   Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves, or in the National Guard, or separated or retired from Armed Forces, Reserves, or the National Guard?

YES, ONLY ONE

YES, MORE THAN ONE

NO [SKIP TO SECTION J]

3.   If yes (answer for up to six people):

3a. What is the relationship of that person (Service Member) to you (circle all that apply):	Mother/Father  Brother/Sister  Spouse/Partner  Child  Other, Specify_____________
3b. Has the Service Member experienced any of the following (circle all that apply):	Deployed in support of Combat Operations      (e.g. Iraq or Afghanistan) Was physically Injured during combat       Operations   Developed combat stress symptoms/difficulties adjusting following deployment, including PTSD,  Depression, or suicidal thoughts  Died or was killed

J. FOLLOW-UP STATUS

[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT FOLLOW-UP]

1. What is the follow-up status of the client? [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 = Located, but refused, unspecified

� 22 = Located, but unable to gain institutional access

� 23 = Located, but otherwise unable to gain access

� 24 = Located, but withdrawn from project

� 31 = Unable to locate, moved

� 32 = Unable to locate, other (SPECIFY) ________________________

2. Is the client still receiving services from your program?

� Yes

� No

[IF THIS IS A FOLLOW-UP INTERVIEW STOP NOW, THE INTERVIEW IS COMPLETE.]

K. DISCHARGE STATUS

[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE]

1. On what date was the client discharged?

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. What is the client’s discharge status?

� 01 = Completion/Graduate

� 02 = Termination

If the client was terminated, what was the reason for termination? [Select one response.]

� 01 = Left on own against staff advice with satisfactory progress

� 02 = Left on own against staff advice without satisfactory progress

� 03 = Involuntarily discharged due to nonparticipation

� 04 = Involuntarily discharged due to violation of rules

� 05 = Referred to another program or other services with satisfactory progress

� 06 = Referred to another program or other services with unsatisfactory progress

� 07 = Incarcerated due to offense committed while in treatment/recovery with satisfactory progress

� 08 = Incarcerated due to offense committed while in treatment/recovery with unsatisfactory progress

� 09 = Incarcerated due to old warrant or charged from before entering treatment/recovery with satisfactory progress

� 10 = Incarcerated due to old warrant or charged from before entering treatment/recovery with unsatisfactory progress

� 11 = Transferred to another facility for health reasons

� 12 = Death

� 13 = Other (Specify)

3. Did the program test this client for HIV?

� Yes [SKIP TO SECTION K.]

� No [GO TO J4.]

4. [IF NO] Did the program refer this client for testing?

� Yes

� No

L. SERVICES RECEIVED

[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE]

Identify the number of DAYS of services provided to the client during the client’s course of treatment/‌recovery. [ENTER ZERO IF NO SERVICES PROVIDED. YOU SHOULD HAVE AT LEAST ONE DAY FOR MODALITY.]

Modality Days

1. Case Management |___|___|___|

2. Day Treatment |___|___|___|

3. Inpatient/‌Hospital (Other Than Detox) |___|___|___|

4. Outpatient |___|___|___|

5. Outreach |___|___|___|

6. Intensive Outpatient |___|___|___|

7. Methadone |___|___|___|

8. Residential/Rehabilitation |___|___|___|

9. Detoxification (Select Only One)

A. Hospital Inpatient |___|___|___|

B. Free Standing Residential |___|___|___|

C. Ambulatory Detoxification |___|___|___|

10. After Care |___|___|___|

11. Recovery Support |___|___|___|

12. Other (Specify) |___|___|___|

Identify the number of SESSIONS provided to the client during the client’s course of treatment/‌recovery. [ENTER ZERO IF NO SERVICES PROVIDED.]

Treatment Services Sessions

[SBIRT GRANTS: You must have at least one session for one of the Treatment Services numbered 1 through 4.]

1. Screening |___|___|___|

2 Brief Intervention |___|___|___|

3. Brief Treatment |___|___|___|

4. Referral to Treatment |___|___|___|

5. Assessment |___|___|___|

6. Treatment/Recovery Planning |___|___|___|

7. Individual Counseling |___|___|___|

8. Group Counseling |___|___|___|

9. Family/Marriage Counseling |___|___|___|

10. Co-Occurring Treatment/‌Recovery Services |___|___|___|

11. Pharmacological Interventions |___|___|___|

12. HIV/AIDS Counseling |___|___|___|

13. Other Clinical Services
(Specify) |___|___|___|

Case Management Services Sessions

1. Family Services (Including Marriage Education, Parenting, Child Development Services) |___|___|___|

2. Child Care |___|___|___|

3. Employment Service

A. Pre-Employment |___|___|___|

B. Employment Coaching |___|___|___|

4. Individual Services Coordination |___|___|___|

5. Transportation |___|___|___|

6. HIV/AIDS Service |___|___|___|

7. Supportive Transitional Drug-Free Housing Services |___|___|___|

8. Other Case Management Services (Specify) |___|___|___|

Medical Services Sessions

1. Medical Care |___|___|___|

2. Alcohol/Drug Testing |___|___|___|

3. HIV/ AIDS Medical Support & Testing |___|___|___|

4. Other Medical Services
(Specify) |___|___|___|

After Care Services Sessions

1. Continuing Care |___|___|___|

2. Relapse Prevention |___|___|___|

3. Recovery Coaching |___|___|___|

4. Self-Help and Support Groups |___|___|___|

5. Spiritual Support |___|___|___|

6. Other After Care Services
(Specify) |___|___|___|

Education Services Sessions

1. Substance Abuse Education |___|___|___|

2. HIV/AIDS Education |___|___|___|

3. Other Education Services
(Specify) |___|___|___|

Peer-To-Peer Recovery Support Services Sessions

1. Peer Coaching or Mentoring |___|___|___|

2. Housing Support |___|___|___|

3. Alcohol- and Drug-Free Social Activities |___|___|___|

4. Information and Referral |___|___|___|

5. Other Peer-to-Peer Recovery Support Services
(Specify) |___|___|___|

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