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pdfOMB No. 0930-0285
Expiration Date 5/21/2013
Transformation Accountability (TRAC)
Center for Mental Health Services
NOMs Client-Level Measures for Discretionary
Programs Providing Direct Services
SERVICES TOOL
Child/Adolescent or Caregiver
Combined Respondent Version
CMHS
Center for Mental Health Services
SAMHSA
March 2011
Version 7
Public reporting burden for this collection of information is estimated to average 30 minutes per
response if all items are asked of a consumer/participant; to the extent that providers already obtain
much of this information as part of their ongoing consumer/participant intake or follow-up, 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 0930-0285.
RECORD MANAGEMENT
Consumer ID
|____|____|____|____|____|____|____|____|____|____|____|
Grant ID (Grant/Contract/Cooperative Agreement) |____|____|____|____|____|____|____|____|____|____|
Site ID
|____|____|____|____|____|____|____|____|____|____|
1. Assessment
Baseline Assessment
6-Month Reassessment
24-Month Reassessment
42-Month Reassessment
60-Month Reassessment
12-Month Reassessment
30-Month Reassessment
48-Month Reassessment
66-Month Reassessment
18-Month Reassessment
36-Month Reassessment
54-Month Reassessment
Clinical Discharge
2. Interview Conducted?
Yes
No
[GO TO 3]
2a. Why was the interview not conducted? Choose only one.
[PLEASE MARK YOUR ANSWER UNDER THE COLUMN RELATING TO THE ASSESSMENT TYPE]
Consumer refused interview
Baseline
Assessment
Clinical
Discharge
Reassessments
Not able to obtain consent from proxy
Consumer was impaired/unable to provide
consent
Consumer cannot be reached for interview
Staff previously indicated “Administrative data
only” or “No data” would be submitted
[IF THIS ANSWER
IS SELECTED, GO
TO SECTION I]
[IF THIS ANSWER
IS SELECTED, GO
TO SECTION J]
[IF THIS IS A CLINICAL DISCHARGE, GO TO 2c]
1
RECORD MANAGEMENT (Continued)
2b. What data will be submitted for the next reassessment?
Interview data
Administrative data only - [Record Management, Sections I or J &K] – will not attempt any subsequent
interviews
No data - will only provide discharge status [Record Management & Section J] when discharged
[GO TO 3]
2c. [CLINICAL DISCHARGE ONLY] What data will be submitted for this Clinical Discharge?
Administrative data only - [Record Management and Sections J &K]
No data – will only provide discharge status [Record Management & Section J]
3. When was the interview conducted or attempted?
[REASSESSMENTS AND CLINICAL DISCHARGE: IF ANSWERED “CONSUMER CANNOT BE REACHED
FOR INTERVIEW” IN 2a, GO TO INSTRUCTIONS BELOW 5]
|____|____| / |____|____| / |____|____|____|____|
MONTH
DAY
YEAR
[IF THIS IS A BASELINE GO TO 4, ALL OTHERS GO TO 5]
4. When did the consumer fir st r eceive ser vices under the gr ant for this episode of car e?
|____|____| / |____|____|____|____|
MONTH
YEAR
5. Was the r espondent the child or the car egiver ?
Child
[PREFER CHILD AGE 11 AND OLDER]
Caregiver
[IF THIS IS A BASELINE, GO TO SECTION A.]
[FOR ALL REASSESSMENTS:
IF AN INTERVIEW WAS CONDUCTED, GO TO SECTION B.]
IF AN INTERVIEW WAS NOT CONDUCTED, GO TO SECTION I.]
[FOR A CLINICAL DISCHARGE:
IF AN INTERVIEW WAS CONDUCTED, GO TO SECTION B.]
IF AN INTERVIEW WAS NOT CONDUCTED, GO TO SECTION J .]
2
A.
DEMOGRAPHIC DATA
[SECTION A IS ONLY COLLECTED AT BASELINE. IF THIS IS NOT A BASELINE, GO TO SECTION B.]
1.
What is your [child’s] gender?
2.
MALE
FEMALE
TRANSGENDER
OTHER (SPECIFY) _____________________________________
REFUSED
Are you [Is your child] Hispanic or Latino?
YES
NO
REFUSED
[GO TO 3]
[GO TO 3]
[IF YES] What ethnic group do you consider yourself [your child]? 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
[IF YES, SPECIFY BELOW]
OTHER
(SPECIFY) ______________________________
3.
What race do you consider yourself [your child]? 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
4.
What is your [your child’s] month and year of birth?
|____|____| / |____|____|____|____|
MONTH
YEAR
REFUSED
[STOP HERE IF BASELINE INTERVIEW WAS NOT CONDUCTED AND DEMOGRAPHIC
DATA WAS ABSTRACTED FROM RECORDS. ALL OTHERS CONTINUE.]
3
B.
FUNCTIONING
1.
How would you rate your [your child’s] overall health right now?
2.
Excellent
Very Good
Good
Fair
Poor
REFUSED
DON’T KNOW
In order to provide the best possible mental health and related services, we need to know what you think
about how well you were [your child was] able to deal with everyday life during the past 30 days. Please
indicate your disagreement/agreement with each of the following statements.
[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER
(CAREGIVER).]
Undecided
Agree
Strongly
Agree
REFUSED
a. I am [my child is] handling daily life.
b. I get [my child gets] along with family
members.
c. I get [my child gets] along with friends and
other people.
d. I am [my child is] doing well in school and/or
work.
e. I am [my child is] able to cope when things go
wrong.
f.
I am satisfied with our family life right now.
NOT
APPLICABLE
Disagree
RESPONSE OPTIONS
Strongly
Disagree
STATEMENT
4
B.
FUNCTIONING (Continued)
[IF THE CAREGIVER IS THE RESPONDENT GO TO THE OPTIONAL GAF QUESTION.]
3.
The following questions ask about how you have been feeling during the past 30 days. For each question,
please indicate how often you had this feeling.
[READ EACH QUESTION FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]
Most
of the
Time
Some of
the Time
A Little
of the
Time
None of
the Time
REFUSED
DON’T
KNOW
RESPONSE OPTIONS
All of the
Time
QUESTION
a. nervous?
b. hopeless?
c. restless or fidgety?
d. so depressed that nothing could cheer you up?
e. that everything was an effort?
f. worthless?
During the past 30 days, about how often did you
feel …
5
B.
FUNCTIONING (Continued)
[IF THE CAREGIVER IS THE RESPONDENT GO TO THE OPTIONAL GAF QUESTION.]
4.
The following questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the
substances we’ll talk about are prescribed by a doctor (like pain medications). But I will only record
those if you have taken them for reasons or in doses other than prescribed.
[READ EACH QUESTION FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]
Once or
Twice
Weekly
Daily or
Almost
Daily
REFUSED
DON’T
KNOW
RESPONSE OPTIONS
Never
QUESTION
a. tobacco products (cigarettes, chewing tobacco, cigars,
etc.)?
b. alcoholic beverages (beer, wine, liquor, etc.)?
b1. [IF B >= ONCE OR TWICE, AND RESPONDENT
MALE], How many times in the past 30 days have you
had five or more drinks in a day?
[CLARIFY IF NEEDED: (A standard alcoholic
beverage (e.g., 12 oz beer, 5 oz wine, 1.5 oz liquor)].
b2. [IF B >= ONCE OR TWICE, AND RESPONDENT
NOT MALE], How many times in the past 30 days
have you had four or more drinks in a day?
[CLARIFY IF NEEDED: (A standard alcoholic
beverage (e.g., 12 oz beer, 5 oz wine, 1.5 oz liquor)].
c. cannabis (marijuana, pot, grass, hash, etc.)?
d. cocaine (coke, crack, etc.)?
e. prescription stimulants (Ritalin, Concerta, Dexedrine,
Adderall, diet pills, etc.)?
f.
methamphetamine (speed, crystal meth, ice, etc.)?
g. inhalants (nitrous oxide, glue, gas, paint thinner, etc.)?
h. sedatives or sleeping pills (Valium, Serepax, Ativan,
Librium, Xanax, Rohypnol, GHB, etc.)?
In the past 30 days, how often have you used…
i.
hallucinogens (LSD, acid, mushrooms, PCP, Special
K, ecstasy, etc.)?
j.
street opioids (heroin, opium, etc.)?
k. prescription opioids (fentanyl, oxycodone [OxyContin,
Percocet], hydrocodone [Vicodin], methadone,
buprenorphine, etc.)?
l.
other – specify:
6
B.
FUNCTIONING (Continued)
[OPTIONAL: GAF SCORE REPORTED BY GRANTEE STAFF AT PROJ ECT’S DISCRETION.]
DATE GAF WAS ADMINISTERED:
|____|____| / |____|____| /|____|____|____|____|
MONTH
DAY
YEAR
WHAT WAS THE CONSUMER’S SCORE?
GAF =
|____|____|____|
[OPTIONAL: CBCL TOTAL PROBLEMS T-SCORE REPORTED BY GRANTEE STAFF AT PROJ ECT’S
DISCRETION.]
DATE CBCL WAS ADMINISTERED:
|____|____| / |____|____| /|____|____|____|____|
MONTH
DAY
YEAR
WHAT WAS THE CONSUMER’S SCORE?
TOTAL PROBLEMS T-SCORE =
|____|____|____|
7
C.
STABILITY IN HOUSING
1.
In the past 30 days how many …
Number of
Nights/
Times
REFUSED
DON’T
KNOW
|____|____|
a.
nights have you [has your child] been homeless?
b.
nights have you [has your child] spent in a hospital for mental
health care?
|____|____|
c.
nights have you [has your child] spent in a facility for
detox/inpatient or residential substance abuse treatment?
|____|____|
d.
nights have you [has your child] spent in correctional facility
including juvenile detention, jail, or prison?
|____|____|
[ADD UP THE TOTAL NUMBER OF NIGHTS SPENT HOMELESS, IN |____|____|
HOSPITAL FOR MENTAL HEALTH CARE, IN DETOX/INPATIENT OR
RESIDENTIAL SUBSTANCE ABUSE TREATMENT, OR IN A
CORRECTIONAL FACILITY. (ITEMS A-D, CANNOT EXCEED 30
NIGHTS)]
e.
times have you [has your child] gone to an emergency room for a
psychiatric or emotional problem?
|____|____|
[IF 1A, 1B, 1C, OR 1D IS 16 OR MORE NIGHTS, GO TO SECTION D.]
2.
In the past 30 days, where have you [has your child] been living most of the time?
[DO NOT READ RESPONSE OPTIONS TO CONSUMER (CAREGIVER). SELECT ONLY ONE.]
CAREGIVER’S OWNED OR RENTED HOUSE, APARTMENT, TRAILER, OR ROOM
INDEPENDENT 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
HOSPITAL (MEDICAL)
HOSPITAL (PSYCHIATRIC)
DETOX/INPATIENT OR RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY
CORRECTIONAL FACILITY (JUVENILE DETENTION CENTER/JAIL/PRISON)
OTHER HOUSED (SPECIFY) _______________________________________________
REFUSED
DON’T KNOW
8
D.
EDUCATION
1.
During the past 30 days of school, how many days were you [was your child] absent for any reason?
0 DAYS
1 DAYS
2 DAYS
3 TO 5 DAYS
6 TO 10 DAYS
MORE THAN 10 DAYS
REFUSED
DON’T KNOW
NOT APPLICABLE
a.
[IF ABSENT], how many days were unexcused absences?
2.
0 DAYS
1 DAYS
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 (your child has) finished, whether or not you (he/she
has) received a degree?
NEVER ATTENDED
PRESCHOOL
KINDERGARTEN
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
9
E.
CRIME AND CRIMINAL JUSTICE STATUS
1.
In the past 30 days, how many times have you [has your child] been arrested?
|____|____| TIMES
REFUSED
DON’T KNOW
[IF THIS IS A BASELINE, GO TO SECTION G. OTHERWISE, GO TO SECTION F.]
10
F.
PERCEPTION OF CARE
[SECTION F IS NOT COLLECTED AT BASELINE. FOR BASELINE INTERVIEWS, GO TO SECTION G.]
1.
In order to provide the best possible mental health and related services, we need to know what you think
about the services you [your child] 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.
[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER
(CAREGIVER).]
Disagree
Undecided
Agree
Strongly
Agree
REFUSED
RESPONSE OPTIONS
Strongly
Disagree
STATEMENT
a. Staff here treated me with respect.
b. Staff respected my family’s religious/spiritual
beliefs.
c. Staff spoke with me in a way that I understood.
d. Staff was sensitive to my cultural/ethnic
background.
e. I helped choose my [my child’s] services.
f.
g. I participated in my [my child’s] treatment.
h. Overall, I am satisfied with the services I [my child]
received.
I helped to choose my [my child’s] treatment goals.
i.
The people helping me [my child] stuck with me [us]
no matter what.
j.
I felt I had [my child had] someone to talk to when I
[he/she] was troubled.
I [my family] got the help I [we] wanted [for my
child].
m. I [my family] got as much help as I [we] needed [for
my child].
k. The services I [my child and/or family] received
were right for me [us].
l.
11
F.
PERCEPTION OF CARE (Continued)
2.
[INDICATE WHO ADMINISTERED SECTION F - PERCEPTION OF CARE TO THE CONSUMER
(CAREGIVER) FOR THIS INTERVIEW.]
ADMINISTRATIVE STAFF
CARE COORDINATOR
CASE MANAGER
CLINICIAN PROVIDING DIRECT SERVICES
CLINICIAN NOT PROVIDING SERVICES
CONSUMER PEER
DATA COLLECTOR
EVALUATOR
FAMILY ADVOCATE
RESEARCH ASSISTANT STAFF
SELF-ADMINISTERED
OTHER (SPECIFY) ____________________________
12
G.
SOCIAL CONNECTEDNESS
1.
Please indicate your disagreement/agreement with each of the following statements. Please answer for
relationships with persons other than your [your child’s] mental health provider(s) over the past 30 days.
[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER
(CAREGIVER).]
Disagree
Undecided
Agree
Strongly
Agree
REFUSED
RESPONSE OPTIONS
Strongly
Disagree
STATEMENT
a. I know people who will listen and understand me
when I need to talk.
b. I have people that I am comfortable talking with
about my [my child’s] problems.
c. In a crisis, I would have the support I need from
family or friends.
d. I have people with whom I can do enjoyable things.
[IF THIS IS A BASELINE, STOP NOW. THE INTERVIEW IS COMPLETE.]
[IF THIS IS A REASSESSMENT INTERVIEW, GO TO SECTION I.]
[IF THIS IS A CLINICAL DISCHARGE INTERVIEW, GO TO SECTION J .]
13
H.
PROGRAM SPECIFIC QUESTIONS
SOME PROGRAMS HAVE PROGRAM SPECIFIC DATA THAT IS SUBMITTED TO TRAC. CMHS
WILL LET YOU KNOW IF YOU ARE REQUIRED TO DO SECTION H, AND YOU WILL HAVE A
SEPARATE SECTION H FORM.
NO CHILD PROGRAMS ARE REQUIRED TO COLLECT DATA FOR SECTION H AT THIS TIME.
14
I.
REASSESSMENT STATUS
[SECTION I IS REPORTED BY GRANTEE STAFF AT REASSESSMENT.]
1.
Have you or other grant staff had contact with the consumer within 90 days of last encounter?
2.
Yes
No
Is the consumer still receiving services from your project?
Yes
No
GO TO SECTION K.
15
J.
CLINICAL DISCHARGE STATUS
[SECTION J IS REPORTED BY GRANTEE STAFF ABOUT THE CONSUMER AT CLINICAL DISCHARGE]
On what date was the consumer discharged?
1.
|____|____| / |____|____|____|____|
MONTH
YEAR
2.
What is the consumer’s discharge status?
Mutually agreed cessation of treatment
Withdrew from/refused treatment
No contact within 90 days of last encounter
Clinically referred out
Death
Other (Specify) __________________________________
IF A DISCHARGE INTERVIEW WAS CONDUCTED, CONTINUE TO SECTION K.
IF A DISCHARGE INTERVIEW WAS NOT CONDUCTED AND:
•
IF STAFF PREVIOUSLY INDICATED “ADMINISTRATIVE DATA ONLY” WOULD BE SUBMITTED,
CONTINUE TO SECTION K.
•
IF STAFF PREVIOUSLY INDICATED “NO DATA” WOULD BE SUBMITTED, STOP HERE.
16
K.
SERVICES RECEIVED
[SECTION K IS REPORTED BY GRANTEE STAFF AT REASSESSMENT AND DISCHARGE UNLESS STAFF
PREVIOUSLY INDICATED “NO DATA” WOULD BE SUBMITTED]
1.
On what date did the consumer last receive services?
|____|____| / |____|____|____|____|
MONTH
YEAR
[IDENTIFY ALL OF THE SERVICES YOUR PROJECT PROVIDED TO THE CONSUMER SINCE HIS/HER
LAST NOMS INTERVIEW; THIS INCLUDES CMHS-FUNDED AND NON-FUNDED SERVICES.]
Core Services
1.
2.
3.
4.
5.
Screening
Assessment
Treatment Planning or Review
Psychopharmacological Services
Mental Health Services
Provided
Yes
No
[IF YES, PLEASE ESTIMATE HOW FREQUENTLY MENTAL HEALTH SERVICES WERE
DELIVERED.]
Number of times ____ _ per
Day
Week
Month
Year
6. Co-Occurring Services
7. Case Management
8. Trauma-specific Services
Yes
No
9. Was the consumer referred to another provider for any of the above core services?
Yes No
Support Services
1. Medical 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. HIV Testing
Provided
Yes
No
11. Was the consumer referred to another provider for any of the above support services?
Yes No
17
| File Type | application/pdf |
| File Title | CMHS NOMs Child Client-level Measures for Discretionary Programs Providing Direct Services Child or Adolescent/Caregive Combined |
| Subject | record management, demographic data, functioning, stability in housing, education, crime and criminal justice status, perception |
| Author | TRAC |
| File Modified | 2011-03-24 |
| File Created | 2010-03-23 |