Form CSAT Instrument CSAT Instrument CSAT Instrument

Common Data Platform

Attachment 6 Final CSAT Instrument 12 19 2014

CSAT Client-Level Data

OMB: 0930-0346

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ATTACHMENT 6

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX















Client-Level Services

Measures for

Discretionary Programs


CSAT PROGRAM ONLY














Public reporting burden for this collection of information is estimated to average 28 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-, 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


SAMHSA Center:


CSAT CMHS CSAP


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


Program Type:


Treatment Grant Program

Recovery Grant Program


Contract/Grant 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 QUESTION 4A)


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

_____________________________________________________________________________________


A1: RECORD MANAGEMENT (CONT.)


4a. Was this an SBIRT grant?


Yes

No (SKIP TO SECTION A2)


THIS SECTION IS FOR SBIRT GRANTS REPORTED AT BASELINE ONLY. ALL OTHER GRANTEES CONTINUE TO SECTION A2.


4b. How did the client screen for your SBIRT?


Negative

Positive


4c. What was his/her screening score?


AUDIT = |____|____|

CAGE = |____|____|

DAST = |____|____|

DAST-10 = |____|____|

NIAAA Guide = |____|____|

ASSIST/Alcohol Subscore = |____|____|

Other (Specify) = |____|____|

______________________________________

______________________________________

______________________________________


4d. Was he/she willing to continue his/her participation in the SBIRT program?


Yes

No



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

Other (SPECIFY): __________________________________

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










SECTION A3

DEMOGRAPHICS (CONT.)


THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE


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. Have you been diagnosed with a learning disability (Autism, Dyslexia, ADHD, etc.)?


Yes

No

Declined

Don’t know / Information not available


12. Have you been diagnosed with a traumatic brain injury (TBI)?


Yes

No

Declined

Don’t know / Information not available




SECTION A3

DEMOGRAPHICS (CONT.)


THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE


13. (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


14. (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


15. (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)





















SECTION A4

MILITARY FAMILY AND DEPLOYMENT (CONT.)


THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE


2b. The following four questions relate to experiences you or a member of your immediate family may have had while serving?




What is the relationship of that person (Service Member) to you:

(IDENTIFY UP TO FIVE RELATIVES IN THE COLUMN HEADINGS. FOR EXAMPLE: MOTHER, FATHER, SISTER, BROTHER, SPOUSE, PARTNER, DAUGHTER, SON, OR OTHER IMMEDIATE RELATIVE).


Has the Service Member experienced any of the following:


(SELF)

Relationship

(Specify):

___________

Relationship

(Specify):

___________

Relationship

(Specify):

___________

Relationship

(Specify):

___________

Relationship

(Specify):

___________

(1) Deployed in support of combat operations (e.g., Iraq or Afghanistan)?

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

(2) Was physically injured during combat operations?

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

(3) Developed combat stress symptoms/ difficulties adjusting following deployment, including PTSD, depression, or suicidal thoughts?

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

(4) Died or was killed?


Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know

Yes

No

Declined

Don’t

know


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.


Offender Reentry Program (ORP) grants should ask about drug use “in the past 30 days prior to incarceration” for questions B1 through B6e at baseline and the “past 30 days” at reassessment and discharge.


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

|____|____| days (IF ZERO, SKIP TO QUESTION 4)

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) (NUMBER OF DAYS IN QUESTION 2 SHOULD BE EQUAL TO OR LESS THAN NUMBER OF DAYS 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) (NUMBER OF DAYS IN QUESTION 2 SHOULD BE EQUAL TO OR LESS THAN NUMBER OF DAYS IN QUESTION 1)

|____|____| days Declined

Don’t know / Information not available


3. (FOR MALES AND FEMALES) In the past 30 days, how many days have you used both alcohol and drugs (on the same day)? (NUMBER OF DAYS IN QUESTION 3 SHOULD BE EQUAL TO OR LESS THAN NUMBER OF DAYS IN QUESTION 1)

|____|____| days 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 (SKIP TO QUESTION 5I)

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








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.)? |____|____| days

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


3. During the past 30 days, how stressful have things been for you because of your use of alcohol or other drugs?

Not at all

Somewhat

Considerably

Extremely

Declined

Don’t know / Information not available


4. During the past 30 days, has your use of alcohol or other drugs caused you to reduce or give up important activities?

Not at all

Somewhat

Considerably

Extremely

Declined

Don’t know / Information not available

SECTION C

FAMILY AND HOUSING (CONT.)


5. During the past 30 days, has your use of alcohol or other drugs caused you to have emotional problems?

Not at all

Somewhat

Considerably

Extremely

Declined

Don’t know / Information not available

_________________________________________________________________________________


6. Are you currently pregnant?

Yes

No

Declined

Don’t know / Information not available


7a. (IF NOT MALE) Do you have any children?

Yes

No (SKIP TO SECTION D)

Declined (SKIP TO SECTION D)

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


7b. If you have any children, how many children do you have? (IF THE ANSWER TO QUESTION 7A IS YES, VALUE IN QUESTION 7B MUST BE GREATER THAN ZERO)

|____|____| children 

Declined

Don’t know / Information not available


7c. If you have any children, how many of your children are living with someone else due to a child protection court order? (THE VALUE IN QUESTION 7C CANNOT EXCEED THE VALUE IN QUESTION 7B)

|____|____| children 

Declined

Don’t know / Information not available


7d. If you have any children, for how many of your children have you lost parental rights? (THE CLIENT'S PARENTAL RIGHTS WERE TERMINATED) (THE VALUE IN QUESTION 7D CANNOT EXCEED THE VALUE IN QUESTION 7B)

|____|____| children 

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.


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

No/Not enrolled

Enrolled, full time

Enrolled, part time

Other (SPECIFY): __________________________________

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 (SKIP TO QUESTION 7)

Unemployed, disabled (SKIP TO QUESTION 7)

Unemployed, volunteer work (SKIP TO QUESTION 7)

Unemployed, retired (SKIP TO QUESTION 7)

Unemployed, not looking for work (SKIP TO QUESTION 7)

Other (SPECIFY): __________________________________

Declined (SKIP TO QUESTION 7)

Don’t know / Information not available (SKIP TO QUESTION 7)


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






SECTION D

EDUCATION, EMPLOYMENT, AND INCOME (CONT.)


7. Approximately, how much money did you receive (pre-tax individual income) in the past 30 days from—

If UNEMPLOYED, NOT LOOKING FOR WORK and value in question 7A is greater than zero, PROBE.

If UNEMPLOYED, LOOKING FOR WORK and value in question 7B is zero, PROBE.

If UNEMPLOYED, RETIRED and value in question 7C is zero, PROBE.

If UNEMPLOYED, DISABLED and value in question 7D is zero, PROBE.


7a. Wages

$ |__|__|__| , |__|__|__|

Declined

Don’t know / Information not available


7b. Public assistance

$ |__|__|__| , |__|__|__|

Declined

Don’t know / Information not available


7c. Retirement

$ |__|__|__| , |__|__|__|

Declined

Don’t know / Information not available


7d. Disability

$ |__|__|__| , |__|__|__|

Declined

Don’t know / Information not available


7e. Non-legal income

$ |__|__|__| , |__|__|__|

Declined

Don’t know / Information not available


7f. Family and/or friends

$ |__|__|__| , |__|__|__|

Declined

Don’t know / Information not available


7g. Other (SPECIFY): ___________________

$ |__|__|__| , |__|__|__|

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 (SKIP TO QUESTION 2)

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


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 QUESTION 1B CANNOT EXCEED VALUE IN QUESTION 1A)  

|____|____| times

Declined

Don’t know / Information not available


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

spent in jail/prison? (If value in question 1A is greater than 15, section C, question 1 must be JAIL/PRISON. If question section C, question 1 is JAIL/PRISON, than value in question 1C must be at least 15.)

|____|____| nights

Declined

Don’t know / Information not available


Offender Reentry Program (ORP) grants please ask if a crime was committed “30 days prior to incarceration” at baseline and “the past 30 days’ at reassessment and discharge.


2. In the past 30 days, how many times have you committed a crime? (The answer to Question 2 must be equal to or greater than the number in section B, Question 4 because using illegal drugs is a crime)

|____|____| times

Declined

Don’t know / Information not available


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

Yes

No

Declined

Don’t know / Information not available











4. Are you currently on parole/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. During the past 30 nights, did you receive inpatient treatment for:


2a. Physical complaint


Yes. SPECIFY number of nights: |____|____|

No

Declined

Don’t know / Information not available


2b. Mental or emotional difficulties


Yes. SPECIFY number of nights: |____|____|

No

Declined

Don’t know / Information not available


2c. Alcohol or substance abuse


Yes. SPECIFY number of nights: |____|____|

No

Declined

Don’t know / Information not available


3. During the past 30 nights, did you receive outpatient treatment for:


3a. Physical complaint


Yes. SPECIFY number of nights: |____|____|

No

Declined

Don’t know / Information not available





SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)


3b. Mental or emotional difficulties


Yes. SPECIFY number of nights: |____|____|

No

Declined

Don’t know / Information not available


3c. Alcohol or substance abuse


Yes. SPECIFY number of nights: |____|____|

No

Declined

Don’t know / Information not available


4. During the past 30 nights, did you receive emergency room/urgent care treatment for:


4a. Physical complaint


Yes. SPECIFY number of nights: |____|____|

No

Declined

Don’t know / Information not available


4b. Mental or emotional difficulties


Yes. SPECIFY number of nights: |____|____|

No

Declined

Don’t know / Information not available


4c. Alcohol or substance abuse


Yes. SPECIFY number of nights: |____|____|

No

Declined

Don’t know / Information not available

_____________________________________________________________________________________


THE FOLLOWING THREE QUESTIONS (5-7) ARE ONLY FOR CLIENTS 10 YEARS OF AGE AND OLDER


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

Yes

No

Declined

Don’t know / Information not available


SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)


6. (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

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

8a. Nervous

8b. Hopeless

8c. Restless or fidgety

8d. So depressed that nothing could cheer you up

8e. That everything was an effort

8f. Worthless

8g. Bothered by the above psychological or emotional problems

Declined

Don’t know / Information not available


7. (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

_____________________________________________________________________________________


8. The following seven questions (8a-8g) ask about how you have been feeling during the past 30 days. For each question, please indicate how often you had this feeling.


SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)


9a. During the past 30 days, did you engage in sexual activity?

Yes

No (SKIP TO QUESTION 10A)

Declined (SKIP TO QUESTION 10A)

Don’t know / Information not available (SKIP TO QUESTION 10A)

Not permitted to ask (SKIP TO QUESTION 10A)


9b. If you engaged in sexual activity in the past 30 days, altogether, did you engage in protected or unprotected—



Yes,

Protected

Yes,

Unprotected

No

Declined

Don't know/

Information not

available

(1) Vaginal sexual

contacts

(2) Oral sexual contacts






(3) Anal sexual contacts







9c. If you engaged in sexual activity in the past 30 days, unprotected sexual contacts were with an individual who is or was:



Yes

No

Declined

Don't know/

Information not

available

(1) HIV positive or has AIDS

(2) An injection drug user





(3) High on some substance





_____________________________________________________________________________


10a. Have you been tested for HIV?


Yes

No (SKIP TO QUESTION 11A)

Declined (SKIP TO QUESTION 11A)

Don’t know / Information not available (SKIP TO QUESTION 11A)

SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)


10b. If you have been tested for HIV, 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 B?


    • Yes

    • No (SKIP TO QUESTION 12A)

    • Decline (SKIP TO QUESTION 12A)

    • Don’t know (SKIP TO QUESTION 12A)


11b. 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


12a. Have you been tested for Hepatitis C?


  • Yes

  • No (SKIP TO SECTION F2)

  • Decline (SKIP TO SECTION F2)

  • Don’t know (SKIP TO SECTION F2)


12b. 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



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 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. In a crisis, I would have the support I need from family or friends.

1b. I feel I belong in my community.


2. To whom do you turn when you are having trouble?

No one

Clergy member

Family member

Friends

Other (SPECIFY): __________________________________

Declined

Don’t know / Information not available



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


_____________________________________________________________________________


3a. Did the program test this client for HIV?


Yes

No (SKIP TO QUESTION 3C)

QUESTIONS

QUESTIONS

Over the past 30 days


Yes

No

1. Have you or other grant staff had contact with the client

within 90 days of the last encounter?

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


3b. If the client was tested for HIV, what was the result?


Negative/Non-reactive (SKIP TO QUESTION 4A)

Positive/Reactive (SKIP TO QUESTION 4A)

Invalid/Indeterminate (SKIP TO QUESTION 4A)

3c. If the client was not tested for HIV, did the program refer this client for testing?

Yes

No

  • Client Declined Testing

_____________________________________________________________________________


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






SECTION I

REASSESSMENT STATUS (CONT.)


THIS SECTION TO BE COMPLETED BY STAFF ONLY AT REASSESSMENT


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)


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



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 this client for HIV?


Yes

No (SKIP TO QUESTION 4C)

4b. If the client was tested for HIV, what was the result?


Negative/Non-reactive (SKIP TO QUESTION 5A)

Positive/reactive (SKIP TO QUESTION 5A)

Invalid/Indeterminate (SKIP TO QUESTION 5A)

4c. If the client was not tested for HIV, did the program refer this client for testing?

Yes

No

  • Client Declined Testing


____________________________________________________________________________


5a. Did the program test the client for Viral Hepatitis?


Yes

No (SKIP TO SECTION K)




SECTION I

REASSESSMENT STATUS (CONT.)


THIS SECTION TO BE COMPLETED BY STAFF ONLY AT REASSESSMENT


5b. 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


5c. 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                       


6a. Did the program conduct a Confirmatory Hepatitis Test?


Yes

No (SKIP TO SECTION K)


6b. 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


6c. 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

PREGNANT AND POSTPARTUM WOMEN (PPW)

THIS SECTION TO BE COMPLETED BY STAFF ONLY


THIS SECTION FOR PPW GRANTEES ONLY


The following direct services are required either under Section 508 of the Public Health Service Act, as amended or by SAMHSA, and are deemed necessary for comprehensive substance abuse prevention, treatment, and recovery support services system for women, their  minor  children, age 17 and under, and other family members.  These services can be provided either by the applicant or through MOUs/MOAs with partners in the network.

SELECT ALL THAT APPLY


1. Women

Outreach, engagement, pre-treatment, screening, and assessment

Detoxification, Medical Assisted Treatment (SELECT ALL THAT APPLY)

For Opioid Addiction

    • Methadone

    • Buprenorphine

    • Naltrexone (Oral)

    • Vivitrol (Injectable)

    • Disulfiram

    • Acamprosate

For Alcohol Addiction

    • Naltrexone (Oral)

    • Vivitrol (Injectable)

    • Disulfiram

  • Acamprosate

Substance abuse education, treatment, and relapse prevention

Medical, dental, and other health care services, including obstetrics, gynecology,

diabetes, hypertension, and prenatal care

Postpartum health care including attention to depression and anxiety disorders, and

medication needs

Specialized assessment, monitoring, and referrals for education, peer support,

therapeutic interventions and physical safety

Mental health care that includes a trauma-informed system of assessments and

interventions

Parenting education and interventions

Home management and life skills training

Education, testing, counseling, and treatment of hepatitis, HIV/AIDS, other STDs,

and related issues;

Employment readiness, and job training and placement

Education and tutoring assistance for obtaining a high school diploma and beyond

Childcare during periods in which the woman is engaged in therapy or in other

necessary health or rehabilitative activities

Peer-to-peer recovery support activities such as groups, mentoring, and coaching

Transportation and other necessary wraparound services

SECTION K

PREGNANT AND POSTPARTUM WOMEN (PPW) (CONT.)


THIS SECTION TO BE COMPLETED BY STAFF ONLY


2. Children


Screenings and developmental diagnostic assessments regarding the social,

emotional, cognitive, and physical status of the infants at birth through

developmental trajectories of the children

Prevention assessments and interventions related to mental, emotional, and

behavioral wellness

Mental health care that includes a trauma-informed system of assessments,

interventions, and social-emotional skill building services

Developmental services and therapeutic interventions, including child care,
counseling, play and art therapy, occupational, speech and physical therapies

Primary and pediatric health care services, including immunizations, and treatment for asthma, diabetes, hypertension, and any perinatal and environmental effects of maternal and/or paternal substance abuse, e.g., HIV, abuse, and neglect

Social services, including financial supports and health care benefits; and

Education and recreational services


3. Family


Family-focused programs to support family strengthening and reunification,

including parenting education and interventions and social and recreational

activities

Alcohol and drug education and referral services for substance abuse treatment

Mental health promotion and assessment, prevention and treatment services, in a

trauma-informed context

Social services, including home visiting, education, vocational, employment,

financial, and health care services


4. Case Management


Coordination and integration of services, and support with navigating systems of

care to implement the individualized and family service plans

Assess and monitor the extent to which required services are appropriate for

women, children, and the family members of the women and children

Assistance with community reintegration, before and after discharge, including

referrals to appropriate services and resources

Assistance in accessing resources from federal, state, and local programs that

provide a range of treatment services, including substance abuse, health, mental

health, housing, employment, education, and training

Connections to safe, stable, and affordable housing that can be sustained over time


End of Section K: Pregnant and Postpartum Women




THIS SECTION TO BE COMPLETED BY STAFF.


ALL PROGRAMS EXCEPT PPW PROGRAMS SHOULD COMPLETE THIS SECTION.


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)


SBIRT GRANTS: You must have at least one session for one of the Treatment Services numbered 2A through 2D.



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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