BASELINE Client Le BASELINE Client Level Survey

VITEL Intake/Baseline Client-Level Survey

Form Approved

OMB No. ####-####

Expiration Date: ##/##/####

Violence Intervention To Enhance Lives (VITEL) Evaluation

INTAKE/BASELINE Client-Level Survey

Funding for data collection supported by the

Center for Substance Abuse Treatment (CSAT)

Substance Abuse and Mental Health Services Administration (SAMHSA)

U.S. Department of Health and Human Services (HHS)

Instructions: These instructions are for program staff administering the VITEL Project Evaluation Client-Level Survey. The Client-Level Survey should be administered by program staff at baseline (based on the program’s definition of baseline), discharge, and 6-months post-baseline to all female clients receiving VITEL services. Please note that this version of the Client-Level Survey is to be used at INTAKE/BASELINE only.

The Client-Level Survey includes seven sections: Background Information, Intimate Partner Violence Risk, Substance Use/Risky Behavior, HIV Testing/HIV Status, Social Support, Mental Health and Medical Health, and Motivation for Treatment. All questions in Sections A – G should be asked of the client.

Please read the introduction to each section (in italics) and then read each question to the client as it is written. For some questions, you will read the response options to clients. Other questions are open-ended and you will not read the response options to clients. Please see the note in italics next to each question to determine whether you should read the response options. Some questions require the use of response options cards. Please provide the response options card to clients when noted.

You may provide clarification to the client to help them in understanding the question, but please do not change the wording of the questions.

The Client-Level Survey should take approximately 25 minutes to administer.

VITEL Evaluation: Client-Level Survey INTAKE/BASELINE
Funding for data collection supported by the Center for Substance Abuse Treatment (CSAT) Substance Abuse and Mental Health Services Administration (SAMHSA) U.S. Department of Health and Human Services (HHS)
Grantee ID		TI0 ___ ___ ___ ___ ___ ___
Partner ID (if applicable)		TI0 ___ ___ ___ ___ ___ ___ - ___ ___ ___
Client ID ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ (Client ID that was assigned to the client must match the DCI / “GPRA” and RHHT forms)
Date of Administration (mm/dd/yyyy)		___ ___ / ___ ___ / ___ ___ ___ ___
PROGRAM STAFF: Please complete the following client background questions using information collected from the Intake/Baseline GPRA.
Client’s Gender Identity	Male (M) Female (F) Transgender (M) Transgender (F) Refused Don’t Know Other (specify) ____________________
Client’s Sexual Orientation	Heterosexual Lesbian (F) Gay (M) Bisexual Refused Don’t Know Other (specify) ________________________
Client’s Ethnicity: Is the client Hispanic or Latino?	Yes No Refused If ‘YES’, what sub-group? Central American Cuban Dominican Mexican Puerto Rican South American Other (specify) _____________
Client’s Race (Mark all that apply)	American Indian / Alaska Native Asian ….. If so, what sub-group? East Asian South Asian Other (specify) ____________________ Black / African American ….. If so, what sub-group (if any)? East African North African Southern African West African Caribbean / West Indian Other (specify) ___________________ Native Hawaiian / Other Pacific Islander White Refused
Client’s Generation (U.S.)	Generation 0 Generation 1 Generation 2+ (Foreign-born) (U.S.-born) (U.S.-born, offspring)
Client’s Age	___ ___

Program Staff: The purpose of these questions is to get more information about how best to provide services. We are asking these questions because it is a requirement for us from the Federal government who gave us funding to provide services to you. All your background information and survey answers will be kept strictly confidential. All survey answers will be provided to the Federal government using only a number for you so there will be no way they can identify who you are. If you have any questions, comments, or concerns they can be directed to XXXXXX, at XXX-XXX-XXXX.

A. Background Information

Program Staff: First, I am going to ask you some questions about yourself.

1. What is your marital status? Do not read response options.

1 Never Married/Single 2 Married 3 Living as Married

4 Separated 5 Divorced 6 Widowed

88 Refused

2. In the past 30 days, with whom did you live? You may say yes to more than one. Please read response options.

Alone With parents

With children alone With other family members

With significant other alone With friends

With significant other and children Jail

Prison Hospital

Residential Treatment Other (specify) _________________

88 Refused

B. Intimate Partner Violence (IPV) Risk

Program Staff: The next set of questions asks about your relationship with your current or former partner or spouse; specifically, I am going to ask you about the frequency with which your partner acts in the ways described. I am going to read each answer option and please use Response Card A to tell us how often these behaviors occur. I realize these questions are very personal, but your open and honest answers are very important. There are no right or wrong answers.

B1. How often does your partner? Please read response options.

Hurt, Insult, Threaten with harm, and Scream at them (HITS)* IPV screening tool
Physically hurt you	1 Never 2 Rarely 3 Sometimes 4 Fairly Often 5 Frequently 88 Refused
Insult or talk down to you	1 Never 2 Rarely 3 Sometimes 4 Fairly Often 5 Frequently 88 Refused
Threaten you with harm	1 Never 2 Rarely 3 Sometimes 4 Fairly Often 5 Frequently 88 Refused
Scream or curse at you	1 Never 2 Rarely 3 Sometimes 4 Fairly Often 5 Frequently 88 Refused
TOTAL SCORE	______________

Clinical Research and Methods (Fam Med 1998;30(7):508-12). HITS is copyrighted in 2003 by Kevin Sherin MD, MPH; for permission to use HITS, Email [email protected] *HITS is used globally in multiple languages, 2006

Program Staff: Please score Section B using the following instructions.

Each item is scored from 1-5. Thus, scores for this inventory range from 4-20. A score of greater

than 10 is considered positive.

C. Substance Use/Risky Behavior

Program Staff: The next set of questions asks about your alcohol or drug use and sexual behaviors.

1. I am going to ask you about your alcohol and drug use on a typical day during the past 30 days. In particular, I am going to ask how many times you used alcohol and specific drugs. Do not read response options.

On a typical day during the past 30 days how many times did you use…
Any Alcohol	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Alcohol to intoxication	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Cocaine/crack (blow, bump, C, candy, Charlie, coke, flake, rock, snow, toot)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Marijuana/hashish (blunt, dope, ganja, grass, herb, joints, Mary Jane, pot, reefer, sinsemilla, skunk, weed, boom, chronic, gangster, hash, hash oil, hemp)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Opiates (oxycontin, oxycodone, brown sugar, dope, H, horse, junk, skag, skunk, smack, white horse, M, Miss Emma, monkey, white stuff, Oxy, O.C., killer)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Non-prescription methadone	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Hallucinogens/psychedelics, PCP, MDMA, LSD, mushrooms, or mescaline (angel dust, boat, hog, love boat, peace pill, Adam, clarity, ecstasy, Eve, lover's speed, peace, STP, X, XTC, acid, blotter, boomers, cubes, microdot, yellow sunshines, magic mushroom, purple passion, shrooms, buttons, cactus, mesc, peyote,)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Methamphetamine or other amphetamines (chalk, crank, crystal, fire, glass, go fast, ice, meth, speed, bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Benzodiazepines (candy, downers, sleeping pills, tranks, Roche, roofies, roofinol, rope, rophies)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Barbiturates (barbs, reds, red birds, phennies, tooies, yellows, yellow jackets)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Non-prescription GHB (G, Georgia home boy, grievous bodily harm, liquid ecstasy)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Ketamine (cat Valiums, K, Special K, vitamin K)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Inhalants (laughing gas, poppers, snappers, whippets)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Both alcohol and drugs on the same day	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused
Other (specify)	Number of times ______ 0 No Past 30 Day Use 66 Don’t Know 88 Refused

***Program Staff: Only ask questions C2 and C3 below to clients who reported no alcohol or drug use in Questions C1a – C1o above. If clients reported alcohol or drug use in Questions C1a – C1o above please skip to question C4 below.***

2. You reported that you did not use alcohol or drugs in the past 30 days? What were your reasons for not using in the past 30 days? You may say yes to more than one. Please read response options.

1 In jail/prison 4 Medical hospitalization

2 On probation/parole 5 Inpatient mental health treatment

3 Lack of money 6 Residential substance use treatment

7 Other (specify) ___________________________

77 Not applicable – used alcohol and/or drugs in the past 30 days.

88 Refused

3. Did you use alcohol or drugs in the past 60 days? Do not read response options.

1 Yes (specify what substances were used in past 60 days) __________

0 No 66 Don’t Know

88 Refused

***Program Staff: If you asked Questions C2 and C3 above, please skip to Question B7 below. ***

4. In the past 30 days, did you inject any of the drugs that you reported using above?

1 Yes 0 No 66 Don’t Know 88 Refused

***Program Staff: If the client answered No, Don’t Know, or Refused to Question C4 above, please skip to Question C7 below.***

5. In the past 30 days, have you shared drug injection equipment (needles/syringes, cotton, cooker, water) without first cleaning it with anything? Do not read response options.

1 Yes (specify how many times) __________

0 No

77 Not applicable – has not used drug injection equipment in the past 30 days.

88 Refused

6. In the past 30 days, did you share drug injection equipment (needles/syringes, cotton, cooker, water) with someone you know had, or suspected of having HIV/AIDS? Do not read response options.

1 Yes (specify how many times) __________

0 No

77 Not applicable – has not used drug injection equipment in the past 30 days.

88 Refused

Program Staff: The next set of questions asks about your sexual behaviors. Again, I realize these questions are very personal, but your open and honest answers are very important.

7. In the past 30 days, did you engage in unprotected sexual activity with a male partner?

1 Yes 0 No 66 Don’t Know 88 Refused

8. In the past 30 days, did you engage in unprotected sexual activity with a female partner?

1 Yes 0 No 66 Don’t Know 88 Refused

9. In the past 30 days, did you engage in unprotected sexual activity with both a male partner and a female partner?

1 Yes 0 No 66 Don’t Know 88 Refused

***Program Staff: Only ask questions C10a – C10j of those clients who reported having unprotected sexual contact during the past 30 days. If the client did not report having unprotected sexual contact during the past 30 days, please skip to Question D1 below.

If the client reported having unprotected sexual contact ONLY with a male partner, please ask only questions C10a, C10c, C10e, C10g, and C10i.

If the client reported having unprotected sexual contact ONLY with a female partner, please ask questions C10b, C10d, C10f, C10h, and C10j.

If the client reported having unprotected sexual contact with BOTH a male partner and a female partner please answer all questions in C10a – C10j. ***

10. In the past 30 days, did you have…?

	Oral Sex	Vaginal Sex	Anal Sex	Did you use any of the following before or during… (check all that apply)
Unprotected sexual contact with a male partner?	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 Alcohol 2 Marijuana 3 Heroin 4 Cocaine/ Crack 5 Other ______ 66 Don’t Know 77 N/A 88 Refused
Unprotected sexual contact with a female partner?	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 Alcohol 2 Marijuana 3 Heroin 4 Cocaine/ Crack 5 Other ______ 66 Don’t Know 77 N/A 88 Refused
Unprotected sex with a male partner in exchange for money, drugs, or shelter?	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 Alcohol 2 Marijuana 3 Heroin 4 Cocaine/ Crack 5 Other ______ 66 Don’t Know 77 N/A 88 Refused
Unprotected sex with a female partner in exchange for money, drugs, or shelter?	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 Alcohol 2 Marijuana 3 Heroin 4 Cocaine/ Crack 5 Other ______ 66 Don’t Know 77 N/A 88 Refused
Unprotected sex with a male partner you know had, or suspected of having a sexually transmitted disease (STD)?	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 Alcohol 2 Marijuana 3 Heroin 4 Cocaine/ Crack 5 Other ______ 66 Don’t Know 77 N/A 88 Refused
Unprotected sex with a female partner you know had, or suspected of having a sexually transmitted disease (STD)?	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 Alcohol 2 Marijuana 3 Heroin 4 Cocaine/ Crack 5 Other ______ 66 Don’t Know 77 N/A 88 Refused
Unprotected sex with a male partner you know had, or suspected of having HIV/AIDS?	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 Alcohol 2 Marijuana 3 Heroin 4 Cocaine/ Crack 5 Other ______ 66 Don’t Know 77 N/A 88 Refused
Unprotected sex with a female partner you know had, or suspected of having HIV/AIDS?	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 Alcohol 2 Marijuana 3 Heroin 4 Cocaine/ Crack 5 Other ______ 66 Don’t Know 77 N/A 88 Refused
Unprotected sex with a male partner you knew was, or suspected of being an injection drug user?	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 Alcohol 2 Marijuana 3 Heroin 4 Cocaine/ Crack 5 Other ______ 66 Don’t Know 77 N/A 88 Refused
Unprotected sex with a female partner you knew was, or suspected of being an injection drug user?	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 # of times ___ 0 No 66 Don’t Know 77 N/A 88 Refused	1 Alcohol 2 Marijuana 3 Heroin 4 Cocaine/ Crack 5 Other ______ 66 Don’t Know 77 N/A 88 Refused

D. HIV Testing/HIV Status

Program Staff: These questions about whether you have ever been tested for HIV and your HIV status as well as other sexually transmitted infections (STIs).

1. In that past 12 months, have you been diagnosed with a sexually transmitted infection (STI) other than HIV? Do not read response options.

1 Yes 0 No 66 Don’t Know 88 Refused

2. Have you ever tested positive for HIV? Do not read response options.

1 Yes 0 No 66 Don’t Know 88 Refused

****Program Staff: If client answered No, Don’t Know, or Refused to Question D2, please skip to Question E1****

3. How long have you known you were HIV positive? Do not read response options.

1 30 days or less 2 Greater than 30 days

66 Don’t Know 77 Not applicable – Not HIV positive.

88 Refused

Program Staff: Next, I am going to ask you some questions about whether you have changed your behavior since you found out you were HIV positive. I am going to read each answer option and please use Response Card B to tell me how much you have changed your behavior. Please select only one choice for each statement. [Please read response options].

	Since you found out you were HIV positive, how much have you changed the following behaviors…	Not at all	A little bit	Moderately	Quite a bit	Extremely	N/A	Refused
	Sharing drug injection equipment (needles/syringes) without first cleaning it with anything?	1	2	3	4	5	77	88
	Sharing drug injection equipment (needles/syringes) with someone you know had, or suspected of having HIV/AIDS?	1	2	3	4	5	77	88
	Having unprotected sexual contact?	1	2	3	4	5	77	88
	Having unprotected sex with someone in exchange for money, drugs, or shelter?	1	2	3	4	5	77	88
	Having unprotected sex with a partner you know had, or suspected of having a sexually transmitted disease (STD)?	1	2	3	4	5	77	88
	Having unprotected sex with a partner you know had, or suspected of having HIV/AIDS?	1	2	3	4	5	77	88
	Having unprotected sex with someone you knew was, or suspected of being an injection drug user?	1	2	3	4	5	77	88
	Having unprotected sex while you were under the influence of drugs or alcohol?	1	2	3	4	5	77	88

Program Staff: Next I am going to ask you some questions about linkages and referral to HIV care and services.

	Since you found out you were HIV positive, have you been engaged in the following activities…	Yes	No	N/A	Refused
	Were you linked to care within 3 months of your HIV diagnosis?	1	0	77	88
	Did you complete the referral to HIV care/services?	1	0	77	88
	Have you been attending routine HIV medical care within 3 months of your diagnosis?	1	0	77	88
	If you have not received routine HIV medical care within 3 months of your diagnosis, have you attended at least one medical care visit within the last six months?	1	0	77	88
	Are you currently receiving antiretroviral therapy (ART)?	1	0	77	88
	If you are not currently receiving ART, have you received ART in the last 6 months?	1	0	77	88
	Has you viral load consistently been <200 copies/mL in the last six months?	1	0	77	88

E. Social Support

Program Staff: Next, I am going to ask you some questions about the important people in your life. I am going to read each answer option and please indicate how much you agree or disagree with each statement below using Response Card C. Please select only one choice for each statement. [Please read response options].

		Disagree Strongly	Disagree	Uncertain	Agree	Agree Strongly	Refused
	You have people close to you who motivate and encourage your recovery.	1	2	3	4	5	88
	You have close family members who help you stay away from drugs.	1	2	3	4	5	88
	You have good friends who do not use drugs.	1	2	3	4	5	88
	You have people close to you who can always be trusted.	1	2	3	4	5	88
	You have people close to you who understand your situation and problems.	1	2	3	4	5	88
	You work in situations where drug use is common.	1	2	3	4	5	88
	You have people close to you who expect you to make positive changes in your life.	1	2	3	4	5	88
	You have people close to you who help you develop confidence in yourself.	1	2	3	4	5	88
	You have people close to you who respect you and your efforts in this program.	1	2	3	4	5	88

10. In the past 30 days, did you attend any self-help groups for recovery (e.g., NA, AA, SMART Recovery)? Do not read response options.

1 Yes (specify how many times) __________

0 No

88 Refused

F. Mental Health and Medical Health

Program Staff: These questions ask about different areas of your life such as your emotional and physical health.

Mental Health

Program Staff: Next I have a list of problems people sometimes have. As I read each one to you, I want you to tell me how much that problem has distressed or bothered you during the past 30 days including today using Response Card B. [Please read response options].

	During the past 30 days, how much were you distressed by…	Not at all	A little bit	Moderately	Quite a bit	Extremely	Refused
	Nervousness or shakiness inside	1	2	3	4	5	88
	Thoughts of ending your life	1	2	3	4	5	88
	Suddenly scared for no reason	1	2	3	4	5	88
	Feeling lonely	1	2	3	4	5	88
	Feeling blue	1	2	3	4	5	88
	Feeling no interest in things	1	2	3	4	5	88
	Feeling fearful	1	2	3	4	5	88
	Feeling hopeless about the future	1	2	3	4	5	88
	Feeling tense or keyed up	1	2	3	4	5	88
	Spells of terror or panic	1	2	3	4	5	88
	Feeling so restless you couldn’t sit still	1	2	3	4	5	88
	Feelings of worthlessness	1	2	3	4	5	88

13. In the past 30 days, how often have you used drugs (including prescription drugs) or alcohol in response to stressful life events? I am going to read each answer option and please use Response Card B to provide your answer. [Please read response options].

1 Not at all 2 A little bit 3 Moderately

4 Quite a bit 5 Extremely 88 Refused

14. In the past 30 days, on how many days did you use drugs or alcohol to help you cope with stressful life events? I am going to read each answer option and please use Response Card B to provide your answer. [Please read response options].

1 Not at all 2 A little bit 3 Moderately

4 Quite a bit 5 Extremely 88 Refused

15. During the past 3 months, did you receive services for mental or emotional difficulties (i.e., inpatient, outpatient, emergency room)? Do not read response options.

1 Yes (specify how many times) __________ 0 No

88 Refused

16. During the past 3 months, were you prescribed a medication for mental or emotional difficulties

(e.g., Prozac, Cymbalta)?

1 Yes (specify medications) __________ 0 No

88 Refused

17. Is this your first time in a substance abuse treatment program? Do not read response options.

1 Yes 0 No 88 Refused

****Program Staff: If client answered Yes to Question F17, please skip to Question F20****

18. How many times have you been in substance abuse treatment before coming to this program? Please read response options.

1 One time 2 2 – 4 times 3 5 – 7 times

4 > than 7 times 77 Not Applicable 88 Refused

19. What type of substance abuse treatment program were you in before coming to this program?

Do not read response options.

1 Outpatient 2 Residential 3 Both 4 Opioid Treatment

77 Not Applicable 88 Refused

Medical Health

20. Why are you enrolling in this treatment program? Do not read response options.

1 Self-admitted 2 Court Mandated 3 Other (specify) _____________

88 Refused

21. Which drug(s) do you want to address in this treatment program?

Specify: ______________________________________________________________________

66 Don’t Know 88 Refused

22. If you are receiving other substance abuse treatment services, how much of your care is provided by this agency/organization? Please read response options.

0 I do not receive other substance abuse treatment services

1 I receive most of my care from this agency/organization

2 I receive about half of my care from this agency/organization and half from another agency/organization

3 I receive most of my care from another agency/organization

Medical Health

23. In the past 30 days, did you have any type of health insurance for yourself? Please read response options.

Yes, private health insurance (e.g., through an employer/union, privately purchased)

Yes, Medicare Yes, other Government health insurance

Yes, Medicaid 0 No

88 Refused

24. During the past 30 days, did you receive medical treatment (not including substance abuse treatment) for physical illness or injury (i.e., inpatient, outpatient, emergency room)? Do not read response options.

1 Yes (specify how many times) __________ 0 No

88 Refused

25. During the past 30 days, for about how many days did poor physical health keep you from doing your usual activities, such as self-care, work, or recreation? Do not read response options.

Number of days __________ 88 Refused

G. Motivation for Treatment

Program Staff: The following questions ask about your attitudes toward substance abuse treatment. Each of the following statements describes a way that you might (or might not) feel about your drug use. For each statement, I am going to read each answer option and please use Response Card D to indicate how much you agree or disagree with each statement right now. [Please read response options].

Note: If the client’s primary substance of choice is alcohol, please replace underlined words with the wording changes suggested in [ ] below.

		Strongly Disagree	Disagree	Undecided or Unsure	Agree	Strongly Agree	Refused
	I have already started making some changes in my use of drugs [drinking].	1	2	3	4	5	88
	I was using drugs [drinking] too much at one time, but I’ve managed to change that [my drinking].	1	2	3	4	5	88
	I’m not just thinking about changing my drug use [drinking], I’m already doing something about it.	1	2	3	4	5	88
	I have already changed my drug use [drinking], and I am looking for ways to keep from slipping back to my old pattern.	1	2	3	4	5	88
	I am actively doing things now to cut down or stop my use of drugs [drinking].	1	2	3	4	5	88
	I want help to keep from going back to the drug [drinking] problems that I had before.	1	2	3	4	5	88
	I am working hard to change my drug use [drinking].	1	2	3	4	5	88
	I have made some changes in my drug use [drinking], and I want some help to keep from going back to the way I used [to drink] before.	1	2	3	4	5	88

End of INTAKE/BASELINE Client Level Survey

Thank you for your time!

Program Staff: Please complete the following section on client drug testing after administration of the INTAKE/BASELINE Client Level Survey. Please consult the client’s medical record as necessary to complete this section.

1. Client/Patient Agree to IPV Referral: Yes No

2. Provider Referred To: ______________________________

3. Date Referral: ____________________________________

4. Case Manager: __________________________________ Telephone #: _____________________

Person Making the Referral: _______________________ Telephone #: _____________________

5. Length of Referral Service: One-time Consultation Ongoing IPV/Trauma Services

6. Type of Service:

Domestic Violence Shelter Legal Transportation

Advocacy Family Counseling Law Enforcement

Court/Judicial Faith-based Medical Services

Support Group

Traditional/Indigenous Healers

7. Appointment Scheduled: Yes No Waiting List If yes, Date/Time: ________________

8. Person Notified at Receiving Agency: ___________________ Telephone #: __________________

9. Date of Notification: ______________________

10. How frequently does your program conduct drug testing? Mark all that apply.

1 Intake 2 At each session 3 Randomly

4 Discharge 5 Post-discharge 6 Never

3 Other (specify) ____________

11. For what reason(s) does your program conduct drug testing? Mark all that apply.

1 Scheduled 2 For Cause 3 Other (specify) ____________

4 At the request of the legal system (e.g., parole officer, court mandated)

12. Has the client received a drug test in the past 90 days?

1 Yes (specify how many times) __________ 0 No 66 Unknown

****Program Staff: Only complete the following questions if the client has received a drug test in the past 90 days ****

13. When did the client last receive a drug test?

Month, Day, Year: __________________________ 66 Unknown

14. What method was used to conduct the client’s most recent drug test?

1 Saliva 2 Blood 3 Urine 4 Hair 5 Sweat 6 Breath

15. Was the sample collection directly observed?

1 Yes (specify how many times) __________ 0 No

16. The client’s most recent drug test checked for the presence of which substances and/or drug groups? Mark all that apply.

Alcohol Amphetamines Barbiturates

Benzodiazepines Cocaine/Crack Marijuana

Methamphetamine Opiates Phencyclidine (PCP)

Other (specify) ____________________________ 66 Unknown

17. What were the results of the client’s most recent drug test?

1 Negative for all drugs tested

2 Positive (specify for which substances) ______________________________

3 Other outcome (i.e., neither negative nor positive), specify ________________________

18. If the test was positive for recent use of alcohol or other drugs, what actions were taken as a result of the positive test?

Client counseled not to use drugs and/or alcohol

More frequent visits required

More frequent drug testing required (specify frequency) _______________________

Other action(s) (specify) _______________________________

RESPONSE CARD A 1 = Never 2 = Rarely 3 = Sometimes 4 = Fairly often 5 = Frequently

RESPONSE CARD B 1 = Not at all 2 = A little bit 3 = Moderately 4 = Quite a bit 5 = Extremely

RESPONSE CARD C 1 = Disagree Strongly 2 = Disagree 3 = Uncertain 4 = Agree 5 = Agree Strongly

RESPONSE CARD D 1 = Strongly Disagree 2 = Disagree 3 = Undecided or Unsure 4 = Agree 5 = Strongly Agree

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 45 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

BL 1