Form CMHS Instrument CMHS Instrument CMHS Instrument

ATTACHMENT 1

Form Approved

OMB No. 0930-XXX

Expiration Date XX/XX/XXXX

Client-Level Services

Measures for

Discretionary Programs

CMHS PROGRAM ONLY

Public reporting burden for this collection of information is estimated to average 23 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 baseline or reassessment, 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 2-1057, 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-xxxx.

A1: RECORD MANAGEMENT

THIS SECTION TO BE COMPLETED BY STAFF ONLY

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

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

Site ID |____|____|____|____|____|____|____|____|____|____|

_____________________________________________________________________________________

1. Interview Type (SELECT ONLY ONE TYPE)

� Baseline

� Reassessment: Three-month follow-up (ADOLESCENT PORTFOLIO ONLY)

� Reassessment: |____|____| months (e.g., enter 06 for six months; enter 12 for one year)

� Discharge: Client completed services

� Discharge: Administrative (SKIP TO SECTION J)

2a. Was the interview conducted?

� Yes

� No (SKIP TO QUESTION 3A)

2b. If an interview was conducted, when did it take place?

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

Month Day Year

__________________________________________________________________________________

3a. Was the client screened by your program for co-occurring mental health and substance use

disorders?

� Yes

� No (SKIP TO SECTION A2)

3b. If the client was screened for co-occurring disorders, did the client screen positive for co-

occurring mental health and substance use disorders?

� Yes

� No (SKIP TO SECTION A2)

BASELINE INTERVIEW, CONTINUE TO SECTION A2

REASSESSMENT AND DISCHARGE INTERVIEWS, SKIP TO SECTION B

End of A1: Record Management

SECTION A2

RECORD MANAGEMENT—PLANNED SERVICES

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

What services do you plan to provide to the client during the client’s course of treatment/recovery?

1. Modality

(CIRCLE AT LEAST ONE MODALITY)

a. Case management Yes No

b. Day treatment Yes No

c. Inpatient/Hospital Yes No

(Other than detox)

d. Outpatient Yes No

e. Outreach Yes No

f. Intensive outpatient Yes No

g. Medication assisted treatment

(CIRCLE ONLY ONE) For Opioid Addiction

(1) Methadone Yes No

(2) Buprenorphine Yes No

(3) Naltrexone ® (Oral) Yes No

(4) Vivitrol ® (Injectable) Yes No

(5) Disulfiram ® Yes No

(6) Acamprosate ® Yes No

For Alcohol Addiction

(1) Naltrexone ® (Oral) Yes No

(2) Vivitrol ® (Injectable) Yes No

(3) Disulfiram ® Yes No

(4) Acamprosate ® Yes No

h. Residential/Rehabilitation Yes No

i. Detoxification (CIRCLE ONLY ONE) (1) Hospital inpatient Yes No

(2) Free standing residential Yes No

(3) Ambulatory detoxification Yes No

j. After care Yes No

k. Recovery support Yes No

l. Other Yes No

(SPECIFY): _________________________

2. Treatment Services (CIRCLE AT LEAST ONE SERVICE)

a. Screening Yes No

b. Brief intervention Yes No

c. Brief treatment Yes No

d. Referral to treatment Yes No

e. Assessment Yes No

f. Treatment/Recovery planning Yes No

g. Individual counseling Yes No

h. Group counseling Yes No

i. Family/Marriage counseling Yes No

j. Co-occurring treatment/

Recovery services Yes No

k. Psycho-Pharmacological

interventions Yes No

l. HIV/AIDS counseling Yes No

m. Mental health services Yes No

n. Other clinical services Yes No

(SPECIFY): ______________________

3. Medical Services

(CIRCLE AT LEAST ONE SERVICE)

a. Medical care Yes No

b. Alcohol/drug testing Yes No

c. HIV/AIDS medical support & testing Yes No

d. Other medical services Yes No

(SPECIFY): ______________________

SECTION A2

RECORD MANAGEMENT—PLANNED SERVICES (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

4. Case Management Services

(CIRCLE AT LEAST ONE SERVICE)

1. Family services (Including marriage

education, parenting, child

development services) Yes No

b. Child care Yes No

c. Employment service

(1) Pre-employment Yes No

(2) Employment coaching Yes No

d. Individual services coordination Yes No

e. Transportation Yes No

f. HIV/AIDS service Yes No

g. Supportive transitional drug-free

housing services Yes No

h. Care coordination Yes No

i. Other case management services Yes No

(SPECIFY): ___________________________

5. After Care Services

(CIRCLE AT LEAST ONE SERVICE)

a. Continuing care Yes No b. Relapse prevention Yes No

c. Recovery coaching Yes No

d. Self-help and support groups Yes No

e. Spiritual support Yes No

f. Other after care services Yes No

(SPECIFY): ____________________________

6. Education Services

(CIRCLE AT LEAST ONE SERVICE)

a. Substance abuse education Yes No

b. HIV/AIDS education Yes No

c. Other education services Yes No

(SPECIFY): ___________________________

7. Peer-To-Peer Recovery Support Services (CIRCLE AT LEAST ONE SERVICE)

a. Peer coaching or mentoring Yes No

b. Housing support Yes No

c. Alcohol-and drug-free social

activities Yes No

d. Information and referral Yes No

e. Other peer-to-peer recovery

support services Yes No

(SPECIFY): ___________________________

CONTINUE TO SECTION A3

End of Section A2: Record Management—Planned Services

SECTION A3

DEMOGRAPHICS

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. What is your date of birth? (MONTH AND YEAR MUST BE ENTERED. DAY IS OPTIONAL)

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

Month Day Year

� Declined

� Don’t know / Information not available

2. Are you Hispanic, Latino/a, or Spanish origin? (SELECT AT LEAST ONE CATEGORY)

� Yes, Central American

� Yes, Cuban

� Yes, Dominican

� Yes, Mexican, Mexican American, Chicano/a

� Yes, Puerto Rican

� Yes, South American

� Yes, another Hispanic, Latino, or Spanish origin (SPECIFY): ___________________________

� No, not of Hispanic, Latino/a, or Spanish origin

� Declined

� Don’t know / Information not available

3. What is your race? (SELECT AT LEAST ONE CATEGORY)

 White

 Black or African American

 American Indian

 Alaska Native

 Native Hawaiian

 Guamanian or Chamorro

 Samoan

 Other Pacific Islander

 Asian Indian

 Chinese

 Filipino

 Japanese

 Korean

 Vietnamese

 Other Asian

� Declined

� Don’t know / Information not available

4a. (ONLY FOR CLIENTS 5 YEARS OF AGE OR OLDER) Do you speak a language other than

English at home?

� Yes

� No (SKIP TO QUESTION 5)

� Declined (SKIP TO QUESTION 5)

� Don’t know / Information not available (SKIP TO QUESTION 5)

SECTION A3

DEMOGRAPHICS (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

4b. If you speak a language other than English at home, what language do you speak?

� Spanish

� Other (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

5. (ONLY FOR CLIENTS 5 YEARS OF AGE OR OLDER) What is your gender?

� Male

� Female

� Transgender

� Different identity (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

6. (ONLY FOR CLIENTS 12 YEARS OF AGE OR OLDER) Which one of the following do you

consider yourself to be?

� Straight

� Lesbian (if female) or Gay (if male)

� Bisexual

� Declined

� Don’t know / Information not available

7. (ONLY FOR CLIENTS 12 YEARS OF AGE OR OLDER) In the past 12 months, who have you had sex with?

� Men only

� Women only

� Both men and women

� I have not had sex in the past 12 months

� Declined

� Don’t know / Information not available

� Not permitted to ask

8. (ONLY FOR CLIENTS 12 YEARS OF AGE OR OLDER) Which statement best describes your

feelings?

[IF MALE] [IF FEMALE]

� I am only attracted to females � I am only attracted to males

� I am mostly attracted to females � I am mostly attracted to males

� I am equally attracted to females and males � I am equally attracted to males and females

� I am mostly attracted to males � I am mostly attracted to females

� I am only attracted to males � I am only attracted to females

� I am not sure � I am not sure

� Declined � Declined

� Don’t know / Information not available � Don’t know / Information not available

__________________________________________________________________________

DISABILITY MEASURES

9. Are you deaf or do you have serious difficulty hearing?

� Yes

� No

� Declined

� Don’t know / Information not available

10. Are you blind or do you have serious difficulty seeing, even when wearing glasses?

� Yes

� No

� Declined

� Don’t know / Information not available

11. (ONLY FOR CLIENTS 5 YEARS OR OLDER) Because of a physical, mental, or emotional

condition, do you have serious difficulty concentrating, remembering, or making decisions?

� Yes

� No

� Declined

� Don’t know / Information not available

12. (ONLY FOR CLIENTS 5 YEARS OR OLDER) Do you have serious difficulty walking or

climbing stairs?

� Yes

� No

� Declined

� Don’t know / Information not available

13. (ONLY FOR CLIENTS 5 YEARS OR OLDER) Do you have difficulty dressing or bathing?

� Yes

� No

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION A4

End of Section A3: Demographics

SECTION A4

MILITARY FAMILY AND DEPLOYMENT

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

QUESTIONS 1A-1E SHOULD ONLY BE ANSWERED IF CLIENT IS 17 YEARS OF AGE OR OLDER. IF CLIENT IS NOT 17 YEARS OF AGE OR OLDER, SKIP TO QUESTION 2A

1a. Have you ever served on active, reserve, or National Guard duty?

� Yes

� No (SKIP TO QUESTION 2A)

� Declined (SKIP TO QUESTION 2A)

� Don’t know / Information not available (SKIP TO QUESTION 2A)

1b. If you ever served on active, reserve, or National Guard duty, in what branch of the military/uniformed services did you serve?

� Army

� Marine Corps

� Navy

� Air Force

� Coast Guard

� PHS

� NOAA

� Declined

� Don’t know / Information not available

1c. If you ever served on active, reserve, or National Guard duty, in which component did you serve?

� Active

� Reserve

� National Guard

� Declined

� Don’t know / Information not available

1d. If you ever served on active, reserve, or National Guard duty, are you currently on active duty or are you separated or retired?

� On active duty

� Separated

� Retired

� Declined

� Don’t know / Information not available

SECTION A4

MILITARY FAMILY AND DEPLOYMENT (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

1e. If you ever served on active, reserve, or National Guard duty, have you ever been deployed to a combat zone? (SELECT ALL THAT APPLY)

� No, never deployed to a combat zone

� Yes, Iraq or Afghanistan (e.g., OEF/OIF/OND)

� Yes, Persian Gulf (Operation Desert Shield/Desert Storm)

� Yes, Vietnam/Southeast Asia

� Yes, Korea

� Yes, Persian Gulf (Operation Desert Shield/Desert Storm)

� Yes, World War II

� Yes, other (SPECIFY COMBAT ZONE): __________________________________

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

For the following questions, immediate family includes your spouse or partner, and your parents, children, brothers and sisters, whether they are biological, step, or adoptive.  Please include these family members whether or not they live with you.

2a. Is anyone in your immediate family currently serving as a member of one the branches of the

United States uniformed services on active duty, reserve components or National Guard?

� Yes

� No (SKIP TO SECTION B)

� Declined (SKIP TO SECTION B)

� Don’t know / Information not available (SKIP TO SECTION B)

2b. If anyone in your immediate family is currently serving in the uniformed services, which member(s) are currently serving? (SELECT UP TO SIX PEOPLE)

� My spouse

� Unmarried partner

� My mother

� My father

� My son or sons

� My daughter or daughters

� My brother or brothers

� My sister or sisters

� Another member of my immediate family (SPECIFY RELATIONSHIP): ________________

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION B

End of Section A4: MILITARY FAMILY AND DEPLOYMENT

SECTION B

DRUG AND ALCOHOL USE

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. In the past 30 days, how many days have you used alcoholic beverages?

|____|____| days (IF ZERO, SKIP TO QUESTION 3)

� Declined

� Don’t know / Information not available

2. (IF MALE)

In the past 30 days, how many days have you used alcohol to intoxication? (DEFINE INTOXICATION AS FOUR OR MORE DRINKS IN A DAY) (VALUE IN QUESTION 2 MUST BE EQUAL TO OR LESS THAN VALUE IN QUESTION 1)

|____|____| days

� Declined

� Don’t know / Information not available

(IF FEMALE)

In the past 30 days, how many days have you used alcohol to intoxication? (DEFINE INTOXICATION AS THREE OR MORE DRINKS IN A DAY) (VALUE IN QUESTION 2 MUST BE EQUAL TO OR LESS THAN VALUE IN QUESTION 1)

|____|____| days

� Declined

� Don’t know / Information not available

3. How much do people risk harming themselves physically or in other ways when they have five or more drinks of an alcoholic beverage once or twice a week?

� No risk

� Slight risk

� Moderate risk

� Great risk

� Declined

� Don't know / Information not available

_____________________________________________________________________________________

4. In the past 30 days, how many days did you use any illegal drugs including prescription drugs

that were taken for reasons or in doses other than prescribed?

|____|____| days (IF ZERO, SKIP TO QUESTION 5I)

� Declined

� Don’t know / Information not available

SECTION B

DRUG AND ALCOHOL USE (CONT.)

5. The following ten questions (5a-5j) relate to your experience with drugs. Some may be

prescribed by a doctor (like pain medication), but I will only record those if you have taken them for reasons or in doses other than prescribed.

 If the value in any question 5a through 5h is more than zero, then the value in question 4 should be more than zero.

 "Route" refers to route of administration. Note the usual route. For more than one route, choose from the following options: (1) Oral, (2) Nasal, (3) Smoking, (4) Non-IV Injection, (5) IV

In the past 30 days, how many days have you used—

5a. Cocaine (coke, crack, etc.)? |____|____| days

� Declined |____| route

� Don’t know / Information not available

5b. Prescription stimulants (Ritalin, Concerta, |____|____| days

Dexedrine, Adderall, diet pills, etc.)? |____| route

� Declined

� Don’t know / Information not available

5c. Methamphetamine (speed, crystal meth, ice, etc.)? |____|____| days

� Declined |____| route

� Don’t know / Information not available

5d. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)? |____|____| days

� Declined |____| route

� Don’t know / Information not available

5e. Sedatives or sleeping pills (Valium, Serepax, Ativan, |____|____| days

Librium, Xanax, Rohypnol, GHB, etc.)? |____| route

� Declined

� Don’t know / Information not available

5f. Hallucinogens (LSD, acid, mushrooms, PCP, |____|____| days

Special K, ecstasy, etc.)? |____| route

� Declined

� Don’t know / Information not available

5g. Street opioids (heroin, opium, etc.)? |____|____| days

� Declined |____| route

� Don’t know / Information not available

5h. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], |____|____| days

hydrocodone [Vicodin], methadone, buprenorphine, etc.)? |____| route

� Declined

� Don’t know / Information not available

SECTION B

DRUG AND ALCOHOL USE (CONT.)

 If the value in any question 5a through 5h is more than zero, then the value in question 4 should be more than zero.

 "Route" refers to route of administration. Note the usual route. For more than one route, choose from the following options: (1) Oral, (2) Nasal, (3) Smoking, (4) Non-IV Injection, (5) IV

5i. Cannabis (marijuana, pot, grass, hash, etc.)? |____|____| day

� Declined |____| route

� Don’t know / Information not available

5j. Other? (SPECIFY): __________________________ |____|____| days

� Declined |____| route

� Don’t know / Information not available

_____________________________________________________________________________________

6. The following five questions (6a-6e) relate to your experience with tobacco or tobacco related products.

In the past 30 days, how many days have you used—

6a. Cigarettes? |____|____| days

� Declined

� Don’t know / Information not available

6b. Chewing tobacco? |____|____| days

� Declined

� Don’t know / Information not available

6c. Cigars? |____|____| days

� Declined

� Don’t know / Information not available

6d. Electronic Cigarettes (e-cigarettes)? |____|____| days

� Declined

� Don’t know / Information not available

6e. Other tobacco related products? |____|____| days

� Declined (SPECIFY): ______________________

� Don’t know / Information not available

CONTINUE TO SECTION C

End of Section B: Drug and Alcohol Use

SECTION C

FAMILY AND HOUSING

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. (DO NOT READ RESPONSE OPTIONS TO CLIENT) In the past 30 days, where have you been

living most of the time?

� Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway

station/airport or anywhere outside)

� Emergency shelter, including hotel or motel

� Staying or living with family/friends (e.g., room, apartment or house)

� Transition Housing

� Substance abuse treatment facility or detox center

� Residential treatment (substance abuse or mental health)

� Therapeutic community or hallway house

� Psychiatric hospital or other psychiatric facility

� Long-term care facility or nursing home

� Hospital or other residential non-psychiatric medical facility

� Permanent supportive housing

� Foster care home or foster care group home

� Jail, prison, or juvenile detention facility

� House rented by client

� House owned by client

� Other (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

2. In the past 30 days, how many nights have you been homeless?

|____|____| nights

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION D

End of Section C: Family and Housing

SECTION D

EDUCATION, EMPLOYMENT, AND INCOME

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1a. Are you currently enrolled in school or job training program? (IF INCARCERATED, SELECT “NO/NOT ENTROLLED”)

� No/Not enrolled (SKIP TO QUESTION 2)

� Enrolled, full time

� Enrolled, part time

� Other (SPECIFY): __________________________________

� Declined (SKIP TO QUESTION 2)

� Don’t know / Information not available (SKIP TO QUESTION 2)

1b. If you are currently enrolled in school or job training program, during the past 30 days, how many days were unexcused absences?

� 0 days

• � 1days

• � 2 days

• � 3 to 5 days

• � 6 to 10 days

• � More than 10 days

• � Declined

• � Don’t know / Information not available

2. What is the highest level of education you have finished (whether or not you received a degree)?

 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

 Some college or university

 Bachelor's degree (BA, BS) or higher

 Vocational/Technical diploma after high school

 I never attended school or a job training program

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

SECTION D

EDUCATION, EMPLOYMENT, AND INCOME (CONT.)

3. Are you currently employed (IF INCARCERATED, SELECT UNEMPLOYED, NOT LOOKING FOR WORK)

 If client is under 16 years of age, SKIP TO SECTION E.

 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 question 1 and indicated EMPLOYED, FULL TIME in question 3, ask for clarification.

 If client is incarcerated and has no work outside of jail, code question 3 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 (SKIP TO SECTION E)

� Unemployed, volunteer work (SKIP TO SECTION E)

� Unemployed, retired (SKIP TO SECTION E)

� Unemployed, not looking for work (SKIP TO SECTION E)

� Other (SPECIFY): __________________________________

� Declined (SKIP TO SECTION E)

� Don’t know / Information not available (SKIP TO SECTION E)

4. Are you paid at or above the minimum wage?

� Yes

� No

� Declined

� Don’t know / Information not available

5. Are your wages paid directly to you by your employer?

� Yes

� No

� Declined

� Don’t know / Information not available

6. Could anyone have applied for your job?

� Yes

� No

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION E

End of Section D: Education, Employment, and Income

SECTION E

CRIME AND CRIMINAL JUSTICE STATUS

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

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

|____|____| times (IF ZERO, SKIP TO QUESTION 2)  

� Declined

� Don’t know / Information not available

1b. Out of the times you have been arrested in the past 30 days, how many times have you

been arrested for drug-related offenses? (VALUE IN 1B CANNOT EXCEED VALUE IN QUESTION 1A)  

|____|____| times

� Declined

� Don’t know / Information not available

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

� Yes

� No

� Declined

� Don’t know / Information not available

3. Are you currently on parole or probation?

� Yes

� No

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION F1

End of Section E: Crime and Criminal Justice Status

SECTION F1

MENTAL AND PHYSICAL HEALTH

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

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

� Excellent

� Very Good

� Good

� Poor

� Declined

� Don’t know / Information not available

2. In order to provide the best possible mental health and related services, we need to know what

you think about how well you were able to deal with everyday life during the past 30 days.

Please indicate your disagreement/agreement with each of the following 12 statements (2a-2l).

2a. I do well in school and/or work.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

2b. I am getting along with my family members.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available / Not applicable

2c. (ONLY FOR CLIENTS 18 YEARS OF AGE OR OLDER) I deal effectively with daily problems.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)

2d. (ONLY FOR CLIENTS 18 YEARS OF AGE OR OLDER) I am able to control my life.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

2e. (ONLY FOR CLIENTS 18 YEARS OF AGE OR OLDER) I am able to deal with crisis.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

2f. (ONLY FOR CLIENTS 18 YEARS OF AGE OR OLDER) I do well in social situations.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

2g. (ONLY FOR CLIENTS 18 YEARS OF AGE OR OLDER) My housing situation is satisfactory.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)

2h. (ONLY FOR CLIENTS 18 YEARS OF AGE OR OLDER) My symptoms are not bothering me.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

2i. (ONLY FOR CLIENTS UNDER 18 YEARS OF AGE) I am handling daily life.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

2j. (ONLY FOR CLIENTS UNDER 18 YEARS OF AGE) I get along with friends and other people.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

2k. (ONLY FOR CLIENTS UNDER 18 YEARS OF AGE) I am able to cope when things go wrong.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)

2l. (ONLY FOR CLIENTS UNDER 18 YEARS OF AGE) I am satisfied with our family life right

now.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

THE FOLLOWING THREE QUESTIONS (3-5) ARE ONLY FOR CLIENTS 10 YEARS OF AGE AND OLDER

3. (ONLY ASK AT BASELINE) Have you ever tried to kill yourself?

� Yes

� No

� Declined

� Don’t know / Information not available

4. (ASK AT REASSESSMENT AND DISCHARGE) At any time in the past 6 months (including

today), did you seriously think about trying to kill yourself?

� Yes

� No

� Declined

� Don’t know / Information not available

5. (ASK AT REASSESSMENT AND DISCHARGE) During the past 6 months (including today), did you try to kill yourself?

� Yes

� No

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

6. In the past 30 days, how many nights have you spent in a hospital for mental health care?

|____|____| nights

� Declined

� Don’t know / Information not available

SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)

7. In the past 30 days, how many nights have you spent in a facility for detox/inpatient or

residential substance abuse treatment?

|____|____| nights

� Declined

� Don’t know / Information not available

8. In the past 30 days, how many times have you gone to an emergency room for a psychiatric or

emotional problem?

|____|____| times

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

9. The following six questions (9a-9f) ask about how you have been feeling during the past 30 days. For each question, please indicate how often you had this feeling.

QUESTIONS	RESPONSE OPTIONS
During the past 30 days, about how often did you feel—	All of the Time	Most of the Time	Some of the Time	A Little of the Time	None of the Time	Declined	Don't know/ Info not Available
9a. Nervous	�	�	�	�	�	�	�
9b. Hopeless	�	�	�	�	�	�	�
9c. Restless or fidgety	�	�	�	�	�	�	�
9d. So depressed that nothing could cheer you up	�	�	�	�	�	�	�
9e. That everything was an effort	�	�	�	�	�	�	�
9f. Worthless	�	�	�	�	�	�	�

SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)

10a. Have you been tested for Hepatitis B?

• Yes

• No (SKIP TO QUESTION 11A)

• Declined (SKIP TO QUESTION 11A)

• Don’t know (SKIP TO QUESTION 11A)

10b. If you have been tested for Hepatitis B, what was the result?

• Negative/Non-Reactive

• Positive/Reactive

• Invalid/Indeterminate

• Declined

• Don’t know/information not available

11a. Have you been tested for Hepatitis C?

• Yes

• No (SKIP TO SECTION F2)

• Declined (SKIP TO SECTION F2)

• Don’t know (SKIP TO SECTION F2)

11b. If you have been tested for Hepatitis C, what was the result?

• Negative/Non-Reactive

• Positive/Reactive

If Positive/Reactive, did you receive a confirmatory test?

• Yes

• No

• Invalid/Indeterminate

• Declined

• Don’t know/information not available

CONTINUE TO SECTION F2

End of Section F1: Mental and Physical Health

SECTION F2

RECOVERY, SELF-HELP, AND PEER-SUPPORT

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. In the past 30 days, have you attended 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. SPECIFY number of times: |____|____|

� No

� Declined

� Don’t know / Information not available

2. In the past 30 days have you attended any religious/faith affiliated recovery self-help groups?

� Yes. SPECIFY number of times: |____|____|

� No

� Declined

� Don’t know / Information not available

3. In the past 30 days, have you attended meetings of organizations that support recovery other

than religious/faith and non-religious faith self-help groups?

� Yes. SPECIFY number of times: |____|____|

� No

� Declined

� Don’t know / Information not available

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

your recovery?

� Yes

� No

� Declined

� Don’t know / Information not available

5. In the past 30 days, I generally accomplished what I set out to do.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

SECTION F2

RECOVERY, SELF-HELP, AND PEER-SUPPORT (CONT.)

6. I feel capable of managing my health care needs.

� On my own most of the time

� With support from others most of the time

� On my own

� Some of the time and with support from others

� Some of the time

� Rarely or never

� Declined

� Don’t know / Information not available

7. I have family or friends that are supportive of my recovery.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION F3

End of Section F2: Recovery, Self-Help, and Peer-Support

SECTION F3

VIOLENCE AND TRAUMA

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

THE FOLLOWING THREE QUESTIONS (1A-1C) TO BE COMPLETED AT BASELINE ONLY

1a. In your life have you ever experienced an event, series of events, or set of circumstances that

resulted in you feeling physically or emotionally harmed or threatened?

� Yes

� No (SKIP TO QUESTION 2)

� Declined (SKIP TO QUESTION 2)

� Don’t know / Information not available (SKIP TO QUESTION 2)

1b. If you ever experienced an event that resulted in you feeling physically or emotionally harmed or threatened, what kind of event was this? (SELECT ALL THAT APPLY)

� Natural or man-made disaster

� Community or school violence

� Interpersonal violence (including physical, sexual or psychological)

� Military trauma

� Other (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

1c. Did any of the above experiences feel so frightening, horrible, or upsetting that in the past and/or the present that you:

(1) Have had nightmares about them or thought about them when you did not want to?

� Yes

� No

� Declined

� Don’t know / Information not available

(2) Tried hard not to think about them or went out of your way to avoid situations that remind

you of them?

� Yes

� No

� Declined

� Don’t know / Information not available

(3) Were constantly on guard, watchful, or easily startled?

� Yes

� No

� Declined

� Don’t know / Information not available

SECTION F3

VIOLENCE AND TRAUMA (CONT.)

(4) Felt numb and detached from others, activities, or your surroundings?

� Yes

� No

� Declined

� Don’t know / Information not available

2. In the past 30 days, how often have you ever experienced an event, series of events, or set of circumstances that resulted in you feeling physically or emotionally harmed or threatened?

Never

A few times

More than a few times

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION G

End of Section F3: Violence and Trauma

SECTION G

SOCIAL CONNECTEDNESS

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. Please indicate your disagreement/agreement with each of the following statements. Please

answer for relationships with persons other than your mental health provider(s) over the past

30 days.

QUESTIONS	RESPONSE OPTIONS
Over the past 30 days—	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	Declined	Don't know/ Info not Available
1a. I had people with whom I did enjoyable things.	�	�	�	�	�	�	�
1b. In a crisis, I would have the support I need from family or friends.	�	�	�	�	�	�	�
1c. (ONLY FOR CLIENTS 18 YEARS OF AGE OR OLDER) I am happy with the friendships I had.
1d. (ONLY FOR CLIENTS 18 YEARS OF AGE OR OLDER) I feel I belong in my community.	�	�	�	�	�	�	�
1e. (ONLY FOR CLIENTS UNDER 18 YEARS OF AGE) I knew people who would listen and understand me when I needed to talk.	�	�	�	�	�	�	�
1f. (ONLY FOR CLIENTS UNDER 18 YEARS OF AGE) I had people that I was comfortable talking with about my problems.	�	�	�	�	�	�	�

CONTINUE TO SECTION H

End of Section G: Social Connectedness

SECTION H

PROGRAM SPECIFIC QUESTIONS

Some programs have program specific data. You will be informed if you are required to complete Section H, and you will have a separate Section H Form.

STOP HERE FOR BASELINE INTERVIEW

CONTINUE TO SECTION I FOR REASSESSMENT

SKIP TO SECTION J FOR DISCHARGE

End of Section H: Program Specific Questions

SECTION I

REASSESSMENT STATUS

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT REASSESSMENT

1. Have you or other grant staff had contact with the client within 90 days of the last

encounter?

� Yes

� No

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

� Yes

� No

_____________________________________________________________________________

3a. Did the program test the client for Viral Hepatitis?

� Yes

� No (SKIP TO SECTION K)

3b. If the client was tested for Viral Hepatitis, did the client receive the test results? (check all that apply)

Hepatitis B � Yes � No

Hepatitis C    � Yes � No

3c. If the client received the Viral Hepatitis test results, what were the results? (check all that apply)

Hepatitis C                          

� Negative/Non-reactive

� Positive/Reactive

� Invalid/Indeterminate

� Not Applicable                       

4a. Did the program conduct a Confirmatory Hepatitis Test?

� Yes

� No (SKIP TO SECTION K)

4b. If the program conducted a Confirmatory Hepatitis Test, did the client receive the results? (check all that apply)

Hepatitis B � Yes � No

Hepatitis C    � Yes � No

SECTION I

REASSESSMENT STATUS (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT REASSESSMENT

4c. If the client received the Confirmatory Hepatitis test results, what were the results?

	Negative/Non-reactive	Positive/Reactive	Invalid/Indeterminate	Not Applicable
Hepatitis B	�	�	�	�
Hepatitis C	�	�	�	�

SKIP TO SECTION K

End of Section I: Reassessment Status

SECTION J

DISCHARGE STATUS

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT DISCHARGE

1. On what date was the client discharged?

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

Month Day Year

2. On what date did the client last receive services?

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

Month Day Year

3. What is the client’s discharge status?

� Mutually agreed cessation of treatment

� Withdrew from/Declined treatment

� No contact within 90 days of last encounter

� Incarcerated (NEWLY OR RE-INCARCERATED)

� Clinically referred out

� Death

� Other (SPECIFY): __________________________________

____________________________________________________________________________

4a. Did the program test the client for Viral Hepatitis?

� Yes

� No (SKIP TO SECTION K)

4b. If the client was tested for Viral Hepatitis, did the client receive the test results? (check all that apply)

Hepatitis B � Yes � No

Hepatitis C    � Yes � No

4c. If the client received the Viral Hepatitis test results, what were the results? (CHECK ALL THAT APPLY)

Hepatitis C                          

� Negative/Non-reactive

� Positive/Reactive

� Invalid/Indeterminate

� Not Applicable                       

5a. Did the program conduct a Confirmatory Hepatitis test?

� Yes

� No (SKIP TO SECTION K)

SECTION J

DISCHARGE STATUS (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT DISCHARGE

5b. If the program conducted a Confirmatory Hepatitis test, did the client receive the results? (CHECK ALL THAT APPLY)

Hepatitis B � Yes � No

Hepatitis C    � Yes � No

5c. If the client received the Confirmatory Hepatitis test results, what were the results?

	Negative/Non-reactive	Positive/Reactive	Invalid/Indeterminate	Not Applicable
Hepatitis B	�	�	�	�
Hepatitis C	�	�	�	�

CONTINUE TO SECTION K

End of Section J: Discharge Status

SECTION K

SERVICES RECEIVED

THIS SECTION TO BE COMPLETED BY STAFF ONLY

Identify the number of DAYS of services or SESSIONS 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)

1. Modality	Days		2. Treatment Services	Sessions
Case Management	|___|___|___|		a. Screening	|___|___|___|
Day Treatment	|___|___|___|		b. Brief Intervention	|___|___|___|
Inpatient/Hospital (Other Than Detox)	|___|___|___|		c. Brief Treatment	|___|___|___|
Outpatient	|___|___|___|		d. Referral to Treatment	|___|___|___|
Outreach	|___|___|___|		e. Assessment	|___|___|___|
Intensive Outpatient	|___|___|___|		f. Treatment/Recovery
Medication Assisted Treatment			Planning	|___|___|___|
For Opioid Addiction			g. Individual Counseling	|___|___|___|
(1) Methadone	|___|___|___|		h. Group Counseling	|___|___|___|
(2) Buprenorphine	|___|___|___|		i. Family/Marriage
(3) Naltrexone ® (Oral)	|___|___|___|		Counseling	|___|___|___|
(4) Vivitrol ® (Injectable)	|___|___|___|		j. Co-Occurring Treatment/
(5) Disulfiram ®	|___|___|___|		Recovery Services	|___|___|___|
(6) Acamprosate ®	|___|___|___|		k. Psycho-Pharmacological
For Alcohol Addiction			Interventions	|___|___|___|
(1) Naltrexone ® (Oral)	|___|___|___|		l. HIV/AIDS Counseling	|___|___|___|
(2) Vivitrol ® (Injectable)	|___|___|___|		m. Mental health services	|___|___|___|
(3) Disulfiram ®	|___|___|___|		n. Other
(4) Acamprosate ®	|___|___|___|		(SPECIFY): __________	|___|___|___|
h. Residential/Rehabilitation	|___|___|___|
i. Detoxification (SELECT ONLY ONE): (1) Hospital Inpatient			3. Medical Services
(2) Free Standing Residential	|___|___|___|		Medical Care	|___|___|___|
(3) Ambulatory Detoxification	|___|___|___|		Alcohol/Drug Testing	|___|___|___|
j. After Care	|___|___|___|		HIV/AIDS Medical Support	|___|___|___|
k. Recovery Support	|___|___|___|		& Testing
l. Other	|___|___|___|		d. Other
(SPECIFY): ____________________	|___|___|___|		(SPECIFY): _____________	|___|___|___|

SECTION K

SERVICES RECEIVED (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY

Identify the number of DAYS of services or SESSIONS provided to the client during the client’s course of treatment/recovery. (ENTER ZERO IF NO SERVICES PROVIDED)

4. Case Management Services	Sessions		6. Education Services	Sessions
a. Family Services (Including Marriage			a. Substance Abuse Education	|___|___|___|
Education, Parenting, Child			b. HIV/AIDS Education	|___|___|___|
Development Services)	|___|___|___|		c. Other
b. Child Care	|___|___|___|		(SPECIFY): ___________	|___|___|___|
c. Employment Service
(1) Pre-Employment	|___|___|___|		7. Peer-to-Peer Recovery Support Services
(2) Employment Coaching	|___|___|___|		a. Peer Coaching or Mentoring	|___|___|___|
d. Individual Services Coordination	|___|___|___|		b. Housing Support	|___|___|___|
e. Transportation	|___|___|___|		c. Alcohol- and Drug-Free
f. HIV/AIDS Service	|___|___|___|		Social Activities	|___|___|___|
g. Supportive Transitional Drug-Free			d. Information and Referral	|___|___|___|
Housing Services	|___|___|___|		e. Other
h. Care coordination	|___|___|___|		(SPECIFY): ___________	|___|___|___|
i. Other
(SPECIFY): ___________________	|___|___|___|
5. After Care Services
a. Continuing Care	|___|___|___|
b. Relapse Prevention	|___|___|___|
c. Recovery Coaching	|___|___|___|
d. Self-Help and Support Groups	|___|___|___|
e. Spiritual Support	|___|___|___|
f. Other After Care Services	|___|___|___|
g. Other
(SPECIFY): ___________________	|___|___|___|

END OF INSTRUMENT

End of Section K: Services Received