Form Client Baseline In Client Baseline In Client Baseline Interview

Attachment 1: Client Interview - Baseline

OMB No. 0930-0320

Expiration Date 03/31/2014

Substance Abuse and Mental Health Services Administration (SAMHSA)

Evaluation of SAMHSA Homeless Programs

Client Interview: Baseline

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

SAMHSA GBHI/SSH Site Number |___|___|___|___|___|

SAMHSA CSAT GPRA/CMHS NOMS 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 0930-0320.  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 (If NO, skip to next section, E1) 77. DON’T KNOW 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. DON’T KNOW 99. REFUSED
M3a. When did you enter the Armed Forces? Please provide year. (if client needs assistance can prompt for service era)	___ ___ ___ ___ (Year Entered) 77. DON’T KNOW 99. REFUSED
M3b. When were you discharged from the Armed Forces? Please provide year.	___ ___ ___ ___ (Year Discharged) 77. DON’T KNOW 88. N/A 99. REFUSED
M4. Have you ever served in a combat theater/zone?	1. YES 0. NO 77. DON’T KNOW 99. REFUSED

Employment

E1. How many days 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 77. DON’T KNOW 99. REFUSED

HOMELESSNESS AND HOUSING

H1. Have you ever been homeless in your lifetime (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 H5) 99. REFUSED

H2. If yes, how old were you the first time you became homeless? _____Yrs old 99. REFUSED

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 (If NONE, skip to H5) 99. REFUSED

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

_____# DAYS 99. REFUSED

[If client cannot answer H3a, then interviewer please use categories to probe and help the client calculate the total number of days spent homeless during the past 3 years.]

• LESS THAN A MONTH

• 1 MONTH TO < 6 MONTHS

• 6 MONTHS TO < 1 YEAR

• 1 YEAR TO < 2 YEARS

• 2 YEARS TO < 3 YEARS

• 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.)? 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 (If NONE, skip to H5) 99. REFUSED

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

_____# DAYS 99. REFUSED

[If client cannot answer H4a, then interviewer please use categories to probe and help the client calculate the total number of days spent homeless during the past 6 months.]

• LESS THAN A WEEK

• 1 WEEK TO < 1 MONTH

• 1 MONTH TO < 3 MONTHS

• 3 MONTHS TO < 6 MONTHS

• ALL SIX MONTHS

H5. Where are you living right now?
01. Your own apartment, house or room (not transitional housing, residential treatment, crisis program or hotel/motel) 02. A friend or relative’s apartment, house or room 03. A community residence or group home 04. Transitional housing like a halfway house, Oxford House, ¾ housing or safe haven (there is a time limit on how long you can stay, like 3 or 6 months or up to 2 years) 05. A residential drug or alcohol treatment program 06. A detoxification program	07. An emergency homeless shelter or family shelter or mission 08. A domestic violence shelter 09. A hotel or motel 10. A crisis program or respite program 11. A psychiatric hospital or psychiatric unit 12. Some other type of hospital 13. Jail or Prison 14. A college dorm 15. On the street or some other place like an abandoned building, a park, or a car 16. Any other place that hasn’t been mentioned, specify:__________. 99. REFUSED
INTERVIEWER, please ask questions H5A-H5C only if the client is currently living in 01- Your own apartment, house or room, 03- A community residence or group home, 04-A transitional housing program, or 05-A residential drug or alcohol treatment program. If you live in your own apartment/house/room, a permanent housing program, a community residence, a group home, a transitional housing program, or a residential drug or alcohol treatment program: H5A. Do you either own your apartment/house/room or do you have a lease in your name? 1. YES, I own. 2. YES, I have a lease in my name. (If YES, answer H5B) 0. NO 77. DON’T KNOW 99. REFUSED H5B. If you have a lease, how long does it last? 1. Less than 6 months 2. 6 months to less than 1 year 3. 1 year to less than 2 years 4. 2 years or more 77. DON’T KNOW 99. REFUSED H5C. Do you receive services to help you keep your housing? 1. YES, at the place where I am living or staying. 2. YES, somewhere other than the place where I am living or staying. 3. YES, both where I am living/staying and in other places. 0. NO 77. DON’T KNOW 99. REFUSED

H6. How many days have you lived there?

_____# DAYS 99. REFUSED

H7. We’d like to know all the places you lived in during the past 6 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	RF
H7a.	Your own apartment, house or room (not transitional housing, residential treatment, crisis program or hotel/motel)	1	0	99
H7b.	A friend or relative’s apartment, house or room	1	0	99
H7c.	A permanent housing program (permanent means there is no time limit on the length of time you can live there) with services where you are living to help you keep your housing	1	0	99
H7d.	A community residence or group home	1	0	99
H7e.	Transitional housing like a halfway house, Oxford House, ¾ housing or safe haven (there is a time limit on how long you can stay, like 3 or 6 months or up to 2 years)	1	0	99
H7f.	A residential drug or alcohol treatment program	1	0	99
H7g.	A detoxification program	1	0	99
H7h.	An emergency homeless shelter or family shelter or mission	1	0	99
H7i.	A domestic violence shelter	1	0	99
H7j.	A hotel or motel	1	0	99
H7k.	A crisis program or respite program	1	0	99
H7l.	A psychiatric hospital or psychiatric unit	1	0	99
H7m.	Some other type of hospital	1	0	99
H7n.	Jail or Prison	1	0	99
H7o.	A college dorm	1	0	99
H7p.	On the street or some other place like an abandoned building, a park, or a car	1	0	99
H7q.	Another place I did not mention (Specify: )	1	0	99

H8. Did you have any problems finding a place to live during the past 6 months? 1. _____YES 0. _____NO (If NO, skip to next question, H10) 99. REFUSED

H9. If yes, what types of problems did you have finding a place to live in the past 6 months? [READ THE TYPES OF PROBLEMS BELOWAND MARK “YES” OR “NO” FOR EACH ITEM.]

		Yes	No	RF
H9a.	Finding a place I could afford	1	0	99
H9b.	Finding a place in a safe neighborhood	1	0	99
H9c.	Having the rent deposit together	1	0	99
H9d.	My credit wasn’t good	1	0	99
H9e.	Problems because of a criminal record	1	0	99
H9f.	Trouble finding a place big enough for my family	1	0	99
H9g.	Finding a place where my partner and I are allowed to live together	1	0	99
H9h.	Finding a place where my children and I are allowed to live together	1	0	99
H9i.	Finding a place near transportation	1	0	99
H9j.	Need to complete treatment before I can get housing.	1	0	99
H9k.	Need to be clean and sober before I can get housing.	1	0	99
H9l.	Discrimination, specify:	1	0	99
H9m.	Other problem, specify:	1	0	99

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. DON’T KNOW 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. DON’T KNOW 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 (including through remand) in the past?	1. YES 0. NO (If NO, skip to next section, TXH1) 77. DON’T KNOW 99. REFUSED
Have you been arrested, booked, or taken into custody (including through remand) in the past 6 months that is since [DATE]?	1. YES 0. NO (If NO, skip to next section, TXH1) 77. DON’T KNOW 88. N/A 99. REFUSED
How many times have you been arrested, booked, or taken into custody (including through remand) in the past 6 months that is since [DATE]?	_________# TIMES 77. DON’T KNOW 88. N/A 99. REFUSED
How many nights did you spend in a holding cell, jail, or prison (including through remand) in the past 6 months that is since [DATE]?	_________ # NIGHTS 77. DON’T KNOW 88. N/A 99. REFUSED

TREATMENT HISTORY, Needs and Services

Have you ever been diagnosed with or treated for alcohol abuse or dependence?	1. YES 0. NO 77. DON’T KNOW 99. REFUSED
Have you ever been diagnosed with or treated for drug abuse or dependence?	1. YES 0. NO 77. DON’T KNOW 99. REFUSED
Have you ever been diagnosed with or treated for schizophrenia, major depression, or bipolar disorder (mania)?	1. YES 0. NO 77. DON’T KNOW 99. REFUSED
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. DON’T KNOW 99. REFUSED
Have you ever been diagnosed with or treated for post-traumatic stress disorder?	1. YES 0. NO 77. DON’T KNOW 99. REFUSED
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. DON’T KNOW 99. REFUSED

RTC1. Have you drunk any alcohol in the past 6 months that is since [DATE]?

1. YES

0. NO (If NO, skip the next set of questions and go to RTC2)

99. REFUSED

If yes, on how many days have you drunk any alcohol in the past 6 months that is since [DATE]?

______# DAYS

99. REFUSED

[If client cannot answer RTC1, then interviewer please use categories to probe and help the client calculate the total number of days he or she drank alcohol in the past 6 months.]

• LESS THAN A WEEK

• 1 WEEK TO < 1 MONTH

• 1 MONTH TO < 3 MONTHS

• 3 MONTHS TO < 6 MONTHS

• ALL SIX MONTHS

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/misused prescription drugs in the past 6 months that is since [DATE]?

1. YES

0. NO (If NO, skip the next set of questions and go to PCL1)

99. REFUSED

If yes, on how many days have you used any illegal drugs/misused prescription drugs in the past 6 months that is since [DATE]?

______# DAYS

99. REFUSED

[If client cannot answer RTC2, then interviewer please use categories to probe and help the client calculate the total number of days he or she used any illegal drugs/misused prescription drugs in the past 6 months.]

• LESS THAN A WEEK

• 1 WEEK TO < 1 MONTH

• 1 MONTH TO < 3 MONTHS

• 3 MONTHS TO < 6 MONTHS

• ALL SIX MONTHS

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 [DATE]. 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 treatment services? <If no, skip to SV2>	1	0	77	88	99
c. How many days did you receive these outpatient substance abuse treatment 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 outpatient mental health services in the past 6 months that is since [DATE]?	___ ___ ____ DAYS			88	99
a. Did you need mental health treatment in an inpatient psychiatric hospital or psychiatric unit where you stayed overnight?	1	0	77	88	99
b. Did you receive any mental health treatment in an inpatient psychiatric hospital or psychiatric unit where you stayed overnight? <If no, skip to SV7>	1	0	77	88	99
c. How many nights or days did you receive mental health treatment in an inpatient psychiatric hospital or psychiatric unit where you stayed overnight in the past 6 months that is since [DATE]?	___ ___ ____ NIGHTS/DAYS			88	99
a. Did you need any trauma-specific treatment; that is, groups or services to address traumatic experiences?	YES	NO	DK	NA	RF
	1	0	77	88	99
b. Did you receive any trauma-specific treatment or services (e.g., TREM (Trauma Recovery Empowerment Motivation), Seeking Safety, 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? <If no, skip to SV9>	1	0	77	88	99
c. How many times did you see a doctor or nurse about your psychiatric medication in the past 6 months that is since [DATE]? (do not include psychiatric hospitals days)	____________ TIMES			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?	YES	NO	DK	NA	RF
	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? <If no, this section is complete. Begin Part II>	1	0	77	88	99
b. If yes, specify:
c. Did you receive these services?	1	0	77	88	99

EVALUATION OF SAMHSA HOMELESS PROGRAMS

Client Interview Part II for Self-Completion — Baseline:

Perception of Care

[Interviewers please note: Two sheets with 16 questions are separately provided to the participant by the GPRA/NOMS interviewer. Please have clients complete these questions on their own and put them into the provided envelope and seal them and return to the interviewer—see Client Informed Consent Script]

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

SAMHSA GBHI/SSH Site Number |___|___|___|___|___|

SAMHSA CSAT GPRA/CMHS NOMS 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/NOMS 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
PC1. I feel free to complain.	1	2	3	4	5
PC2. I was given information about my rights.	1	2	3	4	5
PC3. Staff told me what side effects to watch out for.	1	2	3	4	5
PC4. Staff were sensitive to my cultural background (race, religion, language, etc).	1	2	3	4	5
PC5. I felt comfortable asking questions about my treatment and medication.	1	2	3	4	5
PC6. I, not staff, decided my treatment goals.	1	2	3	4	5
PC7. If I had other choices, I would get services from this agency.	1	2	3	4	5

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. DON’T KNOW 99. REFUSED
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. DON’T KNOW 99. REFUSED
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. DON’T KNOW 99. REFUSED
Are you court-ordered to participate in your program?	1. YES 0. NO 77. DON’T KNOW 99. REFUSED
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. DON’T KNOW 99. REFUSED
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. DON’T KNOW 99. REFUSED
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. DON’T KNOW 99. REFUSED
Were 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. DON’T KNOW 99. REFUSED
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. DON’T KNOW 99. REFUSED