Form CMHS Instrument CMHS Instrument CMHS Instrument

Common Data Platform

Attachment 1 Final CMHS Instrument 12 19 2014

CMHS Client -Level Data

OMB: 0930-0346

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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?


Shape1 Never

Shape2 A few times

Shape3 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

  1. Case Management

|___|___|___|


a. Screening

|___|___|___|

  1. Day Treatment

|___|___|___|


b. Brief Intervention

|___|___|___|

  1. Inpatient/Hospital (Other Than Detox)

|___|___|___|


c. Brief Treatment

|___|___|___|

  1. Outpatient

|___|___|___|


d. Referral to Treatment

|___|___|___|

  1. Outreach

|___|___|___|


e. Assessment

|___|___|___|

  1. Intensive Outpatient

|___|___|___|


f. Treatment/Recovery


  1. 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

|___|___|___|


  1. Medical Care

|___|___|___|

(3) Ambulatory Detoxification

|___|___|___|


  1. Alcohol/Drug Testing

|___|___|___|

j. After Care

|___|___|___|


  1. 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






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