Form Service Use Data C Service Use Data C Service Use Data Collection Form

OMB No. 0930-0277
Expiration Date: XX/XX/XXXX

CMHS Jail Diversion and Trauma Recovery Initiative
Priority to Veterans

SERVICES USE
DATA COLLECTION FORM
2.19.09

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 0930-0277. Public reporting burden for this collection of information is estimated to average 10 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 2-1057, Rockville, Maryland, 20857.

Service Use Form 2.19.09

INSTRUCTIONS:
Complete one form (page 3) per program participant per provider. Broad treatment categories are required (i.e. 0100,
0200, 0300, etc.). Alternatively, specific treatment categories within the broad categories may instead be recorded; we
encourage you to use the most specific code available.
Use one line per treatment episode for
Emergency Room (ER),
Psychiatric inpatient/hospital,
Residential treatment/community living arrangements, and
Detoxification.
All other treatment codes should be listed only once.
Always indicate treatment code, date treatment began, date treatment ended, and number of days OR number of
visits/times to date as well as number of hours, if available. Whether days or times/visits are required depends on the
treatment category (see specific instructions under each TREATMENT CODE category on pages 4 and 5). If episode is
incomplete, enter date treatment ended as 99/99/99.
Data should be collected for one year post-baseline for all major service providers.
NOTE THE FOLLOWING:
If the following services were received as part of an overarching service package (e.g., Assertive Community Treatment
(ACT), psychiatric inpatient/hospital, intensive outpatient treatment), record the overarching service code ONLY:
Individual therapy – any focus,
Group therapy – any focus,
Medication Management/Monitoring,
Case Management,
Any vocational/rehabilitation,
Any community support.

Service Use Form 2.19.09

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EXAMPLES:
Records indicate that a program participant received the following outpatient services from a service provider:
Hour-long individual therapy sessions with an unknown focus from October 18, 2002 to November 17, 2002
(attended 3 sessions) and again from January 4, 2003 to February 20, 2003 (attended 4 sessions).
Group therapy, substance abuse focus every week for 1.5 hours from October 20, 2002 to March 15, 2003
(attended 13 sessions).
Two coding options exist:
a. Code: 0400; Date Tx Began: 10/18/02; Date Tx Ended: 03/15/03; #Visits/Times: 20; Hours: 27
b. Code: 0405; Date Tx Began: 10/18/02; Date Tx Ended: 02/20/03; #Visits/Times: 7; Hours: 7
Code: 0407; Date Tx Began: 10/20/02; Date Tx Ended: 03/15/03; #Visits/Times: 13; Hours: 20
Records indicate that a program participant was hospitalized on the following occasions:
November 18, 2002 to November 26, 2002
January 18, 2003 to January 30, 2003
One coding option exists:
a. Code: 0300; Date Tx Began: 11/18/02; Date Tx Ended: 11/26/02; # Days: 9
Code: 0300; Date Tx Began: 1/18/03; Date Tx Ended: 01/30/03; # Days: 13

Service Use Form 2.19.09

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1. Date of Baseline Interview (MM/DD/YY): __ __ / __ __ / __ __
2. Subject ID: ____ ____- ____ - ____- ____ ____ ____
(Site Code) (Prog #) (Grp #) (Subject ID #)
3. Provider Agency/Organization*: ____________________________________________
*Be sure to complete one form per program participant PER PROVIDER.
Code

Specify

Date Tx Began
(MM/DD/YY)

1

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Date Tx Ended
(MM/DD/YY; enter
99/99/99 if still in
treatment)
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Attach additional sheets as necessary

Service Use Form 2.19.09

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# Days OR
Visits/Times

Check One

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# Days
# Visits/Times
# Days
# Visits/Times
# Days
# Visits/Times
# Days
# Visits/Times
# Days
# Visits/Times
# Days
# Visits/Times
# Days
# Visits/Times
# Days
# Visits/Times
# Days
# Visits/Times
# Days
# Visits/Times

Total # Hours (Round
up to the nearest
whole hour; leave
blank if unknown)
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TREATMENT CODES
0100 = Emergency Room
(Use one line per episode, include start and end date and total
number of days.)
0101 = Physical complaint
0102 = Mental or emotional difficulties
0103 = Alcohol or substance abuse

0400 = Outpatient (excluding Case Management)
(List total number of times/visits--and total number of hours if
known—within time period; start date = first time/visit, end date = last
time/ visit.)
0401 = Individual or family therapy, mental health focus
0402 = Individual or family therapy, substance abuse focus
0403 = Individual or family therapy, mental health &
substance abuse focus
0404 = Individual or family therapy, other focus (specify)
0405 = Individual or family therapy, focus unknown
0406 = Group therapy/specialty groups, mental health
0407 = Group therapy/specialty groups, substance abuse
0408 = Group therapy/specialty groups, mental health &
substance abuse
0409 = Group therapy/specialty groups, other focus (specify)
0410 = Group therapy/specialty groups, focus unknown
0411 = Intensive outpatient treatment/day treatment/partial
hospitalization, mental health
0412 = Intensive outpatient treatment/day treatment/partial
hospitalization, substance abuse
0413 = Intensive outpatient treatment/day treatment/partial
hospitalization, mental health & substance abuse
0414 = Intensive outpatient treatment/day treatment/partial
hospitalization, focus unknown
0415 = Self-help or peer support
0416 = Other (specify)

0200 = Other Crisis Services
(List total number of times used – and total number of hours, if
known – within time period; start date= first day of first time used and
end date = last day of last time used.)
0201 = Mobile crisis services
0202 = Crisis Stabilization Unit
0203 = Crisis residential/respite care
0204 = Other (specify)
0205 = Other (specify)
0300 = Psychiatric Inpatient/Hospital
(Use one line per episode, include start and end date and total
number of days.)

0500 = Case Management
(List total number of times/visits – and total number of hours, if
known – within time period; start date = first time/visit, end date =
time/ visit.)
0501 = Case management
0502 = Intensive case management
0503 = Assertive Community Treatment (ACT)
0504 = Other (specify)
0505 = Other (specify)

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0600 = Medication Management/ Monitoring
(List total number of times/visits – and total number of hours, if
known – within time period; start date = first time/visit, end date =
time/ visit.)

1100 = Community Support
(List total number of times/visits – and total number of hours, if
known – within time period; start date = first time/visit, end date =
time/ visit.)
1101 = Homeless outreach
1102 = Legal or consumer advocacy
1103 = Representative payee services
1104 = Family psychoeducation
1105 = Other (specify)
1106 = Other (specify)

0700 = Residential Treatment/ Community Living Arrangements
(Use one line per episode, include start and end date and total
number of days.)
0701 = Supported housing/living
0702 = Group home, community residence
0703 = Adult home/living facility
0704 = Residential (substance abuse) treatment
0705 = Halfway house (criminal justice)
0706 = Other (specify)
0707 = Other (specify)

1200 = Other Trauma-Specific
(List total number of times/visits – and total number of hours, if
known – within time period; start date = first time/visit, end date =
time/ visit.)
1201 = Cognitive Behavioral Therapy (CBT)
1202 = Dialectical Behavioral Therapy (DBT)
1203 = Eye Movement Desensitization and Reprocessing
(EMDR)
1204 = Addiction and Trauma Recovery Integration Model
(ATRIUM)
1205 = Risking Connection
1206 = Sanctuary Model
1207 = Seeking Safety
1208 = Trauma, Addictions, Mental Health, and Recovery
(TAMAR) Model
1209 = Trauma Affect Regulation: Guide for Education and
Therapy (TARGET)
1210 = Trauma Recovery and Empowerment Model (TREM
and M-TREM)
1211 = Other individual services (specify)
1212 = Other group services (specify)
1213 = Other body/somatic oriented services (specify)
1214 = Other trauma-specific (specify)
1215 = Other trauma-specific (specify)

0800 = Detoxification
(Use one line per episode, include start and end date and
total number of days.)
0801 = Detox program
0802 = Other overnight substance abuse program
0900 = Vocational/Rehabilitation
(List total number of times/visits – and total number of hours, if
known – within time period; start date = first time/visit, end date =
time/ visit.)
0901 = Psychosocial rehabilitation
0902 = Consumer-operated/ peer-run services
0903 = Supported employment
0904 = Vocational counseling
1000 = Jail Services
(List total number of times/visits – and total number of hours, if
known – within time period; start date = first time/visit, end date =
time/ visit.)

Service Use Form 2.19.09

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1300 = Housing Services
(Use one line per episode, include start and end date and total
number of days.)
1301 = Help in placement or locating housing
1302 = Help remaining in housing (voucher or subsidy,
negotiation with landlord or other actions to prevent
eviction, etc.)
1303 = Shelter services
1304 = Transitional housing services
1400 = Transportation Services
(Use one line per episode, include start and end date and total
number of days.)
1500 = Child Care Services
(Use one line per episode, include start and end date and total
number of days.)
1600 = Social or Recreational Services
(Use one line per episode, include start and end date and total
number of days.)

Service Use Form 2.19.09

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