Client Interaction Form

OMB No. 0930-####

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

VIOLENCE INTERVENTION TO ENHANCE LIVES (VITEL) ProJECT

Evaluation Project

Client INTERACTION Form

Grantee Name:	__________________________________________
Grantee ID Number:	__________________________________________
Client ID Number (same as GPRA ID)	__________________________________________
Date Completed:	_______ /	_______ /	_________
	Month	Day	Year

Notice to Respondents

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 60 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.

Interaction Instructions and Client Interaction Form

Interaction Measurement

Individual clients in a program can have very different types and amounts of contact (i.e., interaction) due to absences, participation in different components, or dropping out; thus it is critical to have interaction information to accurately assess program effects. Interaction is a measure of the type and amount of contact that a client has with the program.

The documentation of client exposure to program services is an important feature of the CSAT Violence To Enhance Lives (VITEL) evaluation. The interaction measurement developed for this evaluation study is designed to meet several criteria. First, the client interaction form must reflect the actual services and activities of the funded programs. Second, the client interaction form must be simple enough to implement across all grantees. Third, the client interaction form should be completed only at six month follow-up.

VITEL Evaluation Interaction General Instructions

Interaction measurement applies only to those services that directly involve VITEL clients. Interaction data will not be collected on services for which the client is not individually involved, such as case management review meetings. Most direct services will involve face-to-face contact between the client and service provider, but there may be some direct services provided over the telephone such as crises intervention or case management counseling. Program services and treatment activities included are only those provided directly by the grantee or through contractual arrangements. Because interaction is a measurement of program exposure to services and treatment activities, interaction data will be collected on VITEL clients only.

There is no expectation that a program would conduct activities in all of the service/treatment activities categories listed in the client interaction form. However, for the purposes of interaction recording, it is important that each program activity be attached to one of these intervention types.

Some program encounters will involve only one intervention type, e.g., a family counseling session. However, clients can receive more than one type of service or treatment activity during a daily encounter. For example, as part of a daily program encounter clients may learn about the harmful effects of alcohol, tobacco, and drugs (Substance Use Disorder Education) during the first hour and then during the second hour participate in a group substance use disorder counseling (Group Substance Use Disorder Treatment Counseling) session and spend a third hour working on exercises to improve parent-child communication (Parenting Skills Education). Two tables provided below contain definitions to assist in completing the client interaction form. Table 1 has definitions of the treatment modalities for completing the first section of the client interaction form and Table 2 has definitions on various service and treatment activities for the completion of the second section of the client interaction form.

Completing the Client Interaction Form

Below are some suggestions that will facilitate your completion of the Client Interaction Form. Please complete one form for each VITEL client in your program.

1. Complete a Client Interaction Form for each VITEL client at discharge. The definition of discharge should follow your program definition. If your program does not have a definition of discharge, the Client Interaction Form should be completed when the client has had no contact with the program for 30 days.

2. It is critical that you are familiar with the form and have the client’s chart/records (or other records of client’s services received and activities) available prior completing the form. Give yourself about 15 minutes to complete the form once you have the client’s records.

INSTRUCTIONS FOR COMPLETION

DATE: Please fill in the date you complete the form.

CLIENT IDENTIFICATION: Enter the client’s program identification number. The client’s ID number should be the same number assigned to the client for her GPRA administration.

PERSON COMPLETING FORM: Fill in your name as the person completing the form.

GRANT NUMBER: Enter your grant identification number starting with TI0.

QUESTION 1[LENGTH OF STAY]: To complete this question you will need to refer to the client’s treatment records to assess how many days the client spent in your treatment program and place an “X” in the box next to the corresponding number of days the client spent in treatment.

QUESTION 2 [TYPE OF TREATMENT]: For this question you will need to indicate the type of treatment the client engaged in while in your program. Please refer to Table 1 for clarification if you are uncertain of the type of treatment. Please check the appropriate box (es) for the type of treatment the client engaged in while in your program.

Table 1: Interaction Treatment Modalities

treatment modality

Outpatient: This modality is for clients who require treatment that entails group education, activity therapy, etc., lasting more than 4 continuous hours in a supportive environment.

Intensive Outpatient: This modality consists of intense multimodal treatment for clients who require frequent treatment in order to improve, while still maintaining family, student, or work responsibilities in the community. Intensive outpatient services differ from outpatient by the intensity and number of hours per week. Intensive outpatient services are provided 2 or more hours per day for 3 or more days per week.

Methadone: This modality includes the provision of methadone maintenance for opioid-addicted clients.

Residential: This modality is for a residential facility that provides onsite structured therapeutic and supportive services specifically for alcohol and other drugs.

SERVICE/TREATMENT ACTIVITIES: These series of statements refer to the services and treatment activities a client received or in which they participated. Please refer to Table 2 if you need a definition for the service/treatment activity. Begin with the first service/treatment activity and look across to the column labeled “A­ Services Received.” Choose the response category (i.e., 1=yes, 0=no, -1=N/A, -8= Don’t know) for this service or treatment activity and record the number in column A. If you record a N/A (-1) for receiving a service in Column A, then it is anticipated that the client will also receive N/A or in Columns B-C. Repeat the same process for Columns B and C. Go through each of the service/treatment activity and repeat the process until you are finished.

Table 2: Interaction Service/Treatment Activities

Service/treatment activities

Case Management Services: These services involve direct services between the client and the case manager, including individual assessments, service plan development and evaluation, arranging for and monitoring needed services, making and following up on referrals, and other case management services as defined by the program. Routine telephone calls are not included.

Parenting Skills Education: Activities included in this category include instruction on developmental expectations parents should have given their child’s age, provision of information about positive parenting practices and forms of discipline, lessons on parent-child communication, and other parenting-related information.

Family Counseling: Activities included in this category include relationship-building activities conducted with the client and family members together, family mediation, family counseling (individual family or multi-family), parenting counseling (individual or group), and self-help/support groups for clients.

Physical Exam: The category includes any physical examination by a licensed professional such as a medical doctor, nurse practitioner, or physician’s assistant that includes assessment of height, weight, vital signs, BMI, body systems: respiratory, cardiac, gastrointestinal, genito-urinary, skin, and neurological.

Educational Services: This category includes activities such as tutoring assistance to improve reading, literacy, and math skills or other educational activities leading to a high school diploma, GED or higher education.

Employment Placement/Vocational Support: Vocational support activities are also included in this category, such as career counseling, job training, resources provided to clients to assist in finding employment, and job placement.

Life Skills Training: Activities in this category focus on training on specific personal or interpersonal skills that have been identified as important to successful individual and social development. This category includes skills development training that targets competencies, such as communication, decision making, problem solving, conflict resolution, refusal skills, as well as more general life skills (e.g., budgeting, cooking). Also included in this category are program sessions that specifically address self-esteem, self-concept, and self-confidence building.

Positive Recreation and Enrichment: This category includes a broad range of program activities that share a primary concern about leisure time activities that take place in a drug-free environment, are appealing to client, and may contribute to enrichment or skills development by providing an opportunity to engage in stimulating and rewarding activities. Activities in this category may be loosely structured, e.g., self-care time and group meals, or more structured activities such as crafts courses or art classes.

Substance Use Disorder Education: This category includes education, training, or discussion sessions that focus directly or indirectly on information concerning ATOD awareness, knowledge, or use. The category also includes training or education on risk situations specifically related to ATOD use, such as HIV/AIDS, and antiviolence awareness.

Intimate Partner Violence (IPV)/Trauma-Informed Services: Activities in this category focus on screening, which is a brief process that determines current, past, or risk for trauma to include IPV; assessments which occur after screening and consists of gathering key information to collaboratively conceptualize the problem and develop a treatment plan including safety assessment of health impact, and risk of suicide/homicide; and trauma-specific interventions that directly address trauma and its impact, and that facilitate trauma recovery (e.g., Addiction and Trauma Recovery Integration Model [ATRIUM], Seeking Safety, Trauma Recovery and Empowerment Model [TREM; & M-TREM]).

Rapid HIV Testing and Counseling: Included in this category are the private pre- and post-test counseling sessions associated with each rapid HIV testing session.

HIV Prevention Education: Activities in this category focus on training on specific personal or interpersonal skills that have been identified as important to prevent or reduce the risk for HIV infection. This category includes skills for condom negotiation, practicing safer sex, and awareness of barrier methods and microbicides.

HIV/AIDS Medical Treatment and Care: This category includes HIV treatments such as antiretrovirals (ARVs), Highly Active Antiretroviral Therapy (HAART), Pre-Exposure Prophylaxis (PrEP), as well as care components inclusive of CD4 monitoring, viral load suppression, and medication adherence,

Childcare: This category includes care provided to children for a duration of time so clients can participate in individual and group activities or receive services.

Relapse Prevention: This category includes the activities and processes for identifying each client’s current stage of recovery and establishing a recovery plan to identify and manage the relapse warning signs.

Social Support Groups: Included in this category are the sessions clients engage in to help or improve oneself with assistance from others; and/or an assemblage of persons who have similar experiences and assist in encouraging and keeping individuals from failing.

Spiritual Activity: Included in this category is spiritual/religion-based support for the clients’ recovery process (meditational activities, attendance at services, watching video tapes, listening to tapes, etc.)

2 0

DATE: |__|__| |__|__| |__|__|__|__| CLIENT’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

DF_MO DF_DY DF_YR DF_CLIENT

(Client ID assigned to the client must match on DCI / “GPRA” and RHHT forms)

PERSON COMPLETING |_______________| GRANT# TI0|__|__|__|__|__|

DF_INTERVIEWER DF_SITE

CLIENT INTERACTION FORM

At the time a client is discharged from treatment, this is to be completed by project staff based on review of each client’s treatment records.

1. Length of stay DF_LENGTH_STAY Less than 30 days 1 30 days 2 31 – 45 days 3 46 – 60 days 4 61 – 90 days 5 91 – 120 days 6 121 – 180 days 7 181 – 270 days 8 More than 270 days 9

2. Treatment modality (check all that apply) DF_TREATMENT_MODALITY Outpatient 1 Intensive Outpatient 2 Methadone 3 Residential 4

Column ‘A’ Responses Services Received 1 = Yes 0 = No -1 = N/A -8 = Don’t know

Column ‘B’ Responses Number of Sessions 0 = No sessions 1 = Once 2 = Monthly 3 = 2-3 x/month 4 = Weekly 5 = 2-4 x/week 6 = 5-6 x/week 7 = Daily -1 = N/A

Column ‘C’ ResponsE Where and by Whom 1 = On-site by project staff 2 = On-site by another agency 3 = Off-site by project staff 4 = Off-site by another agency 5 = On-site by parent organization staff 6 = Off-site by parent organization staff -1 = N/A

In the following section, choose the response category that most closely describes the services received by this client. Record the corresponding value in the box for each column: A – Services Received, B – Number of Sessions, and

C – Where and by Whom. Please note for Column C you can enter more than one number as appropriate for where services were received.

If a client is given a N/A for receiving a service in Column A, then it is anticipated that the client will also receive N/A or NONE in Columns B-C.

SERVICE/TREATMENT ACTIVITY
	A Services Received	B Sessions	C Where and by Whom
Pretreatment Services	|___| DF_STA01_A	|___| DF_STA01_B	|___| DF_STA01_C
Rapid HIV Counseling & Testing	|___| DF_STA02_A	|___| DF_STA02_B	|___| DF_STA02_C
Viral Hepatitis Testing and Counseling	|___| DF_STA03_A	|___| DF_STA03_B	|___| DF_STA03_C
Substance Use Disorder Education	|___| DF_STA04_A	|___| DF_STA04_B	|___| DF_STA04_C
HIV Prevention Education, including prevention education for :)	|___| DF_STA05_A	|___| DF_STA05_B	|___| DF_STA05_C
a. Safe sex practices	|___| DF_STA05a_ SAFE_A	|___| DF_STA05a_ SAFE_B	|___| DF_STA05a_ SAFE_C
b. Condom negotiation skills	|___| DF_STA05b_ CONDOM_A	|___| DF_STA05b_ CONDOM_B	|___| DF_STA05b_ CONDOM_C
c. Barrier protection methods	|___| DF_STA05c_ BARRIER_A	|___| DF_STA05c_ BARRIER_B	|___| DF_STA05c_ BARRIER_C
d. Peer Education	|___| DF_STA05d_ PEER_A	|___| DF_STA05d_ PEER_B	|___| DF_STA05d_ PEER_C
e. HIV risk in pregnancy & childbirth	|___| DF_STA05e_ PREGNANT_A	|___| DF_STA05e_ PREGNANT_B	|___| DF_STA05e_ PREGNANT_C
Sexually Transmitted Infections Screening and Treatment	|___| DF_STA06_A	|___| DF_STA06_B	|___| DF_STA06_C
Medical Diagnosing and Follow-up Treatment	|___| DF_STA07_A	|___| DF_STA07_B	|___| DF_STA07_C
Physical Exam by Healthcare Providers (including height, weight, vital signs, BMI, body systems: respiratory, cardiac, gastrointestinal, genitor-urinary, skin, neurological)	|___| DF_STA08_A	|___| DF_STA08_B	|___| DF_STA08_C
Laboratory Testing (urinalysis, complete blood count, electrolytes)	|___| DF_STA09_A	|___| DF_STA09_B	|___| DF_STA09_C
Substance Use Disorder (SUD) Treatment Planning	|___| DF_STA10_A	|___| DF_STA10_B	|___| DF_STA10_C
Mental Health Assessment	|___| DF_STA11_A	|___| DF_STA11_B	|___| DF_STA11_C
Mental Health Treatment	|___| DF_STA12_A	|___| DF_STA12_B	|___| DF_STA12_C
Group Psychiatric Therapy (based on psychiatric diagnosis)	|___| DF_STA12_A	|___| DF_STA12_B	|___| DF_STA12_C

SERVICE/TREATMENT ACTIVITY (continued)
	A Services Received	B Sessions	C Where and by Whom
Individual Psychiatric Therapy (based on psychiatric diagnosis)	|___| DF_STA14_A	|___| DF_STA14_B	|___| DF_STA14_C
Individual Substance Use Disorder Treatment Counseling	|___| DF_STA15_A	|___| DF_STA15_B	|___| DF_STA15_C
Group Substance Use Disorder Treatment Counseling	|___| DF_STA16_A	|___| DF_STA16_B	|___| DF_STA16_C
Gender Specific Sessions	|___| DF_STA17_A	|___| DF_STA17_B	|___| DF_STA17_C
IPV screening	|___| DF_IPV18_A	|___| DF_IPV18_B	|___| DF_IPV18_C
IPV assessment	|___| DF_IPV19__A	|___| DF_IPV19_B	|___| DF_IPV19_C
IPV intervention	|___| DF_IPV20_A	|___| DF_IPV20_B	|___| DF_IPV20_C
Other trauma-informed services	|___| DF_TIA21_A	|___| DF_TIA21_B	|___| DF_TIA21_C
Case Management Services	|___| DF_STA22_A	|___| DF_STA22_B	|___| DF_STA22_C
Social Support Groups	|___| DF_STA23_A	|___| DF_STA23_B	|___| DF_STA23_C
Aftercare Planning	|___| DF_STA24_A	|___| DF_STA24_B	|___| DF_STA24_C
Life Skills Training	|___| DF_STA25_A	|___| DF_STA25_B	|___| DF_STA25_C
Employment Readiness Training	|___| DF_STA26_A	|___| DF_STA26_B	|___| DF_STA26_C
Employment Placement	|___| DF_STA27_A	|___| DF_STA27_B	|___| DF_STA27_C
Recreational Activity (field trips, movies, team sports, cultural experiences, picnics)	|___| DF_STA28_A	|___| DF_STA28_B	|___| DF_STA28_C
Spiritual Activity (meditational activities, attendance at services, watching video tapes, listening to tapes, etc.)	|___| DF_STA29_A	|___| DF_STA29_B	|___| DF_STA29_C
Transitional Housing	|___| DF_STA30_A	|___| DF_STA30_B	|___| DF_STA30_C
Permanent Housing Arrangements	|___| DF_STA31_A	|___| DF_STA31_B	|___| DF_STA31_C
Educational Services (for GED and other educational needs)	|___| DF_STA32_A	|___| DF_STA32_B	|___| DF_STA32_C

SERVICE/TREATMENT ACTIVITY (continued)
	A Services Received	B Sessions	C Where and by Whom
Vocational Services	|___| DF_STA33_A	|___| DF_STA33_B	|___| DF_STA33_C
Childcare	|___| DF_STA34_A	|___| DF_STA34_B	|___| DF_STA34_C
Transportation	|___| DF_STA35_A	|___| DF_STA35_B	|___| DF_STA35_C
Parenting Skills Education	|___| DF_STA36_A	|___| DF_STA36_B	|___| DF_STA36_C
Family Counseling	|___| DF_STA37_A	|___| DF_STA37_B	|___| DF_STA37_C
Discharge Planning (including community reintegration, socio-economic support at State and Federal level if eligible)	|___| DF_STA38_A	|___| DF_STA38_B	|___| DF_STA38_C
Planned or Arranged Post Treatment Continuing Care	|___| DF_STA39_A	|___| DF_STA39_B	|___| DF_STA39_C

Column ‘A’ Responses Services Received 1 = Yes 0 = No -1 = N/A -8 = Don’t know

Column ‘B’ Responses Number of Sessions 0 = No sessions 1 = Once 2 = Monthly 3 = 2-3 x/month 4 = Weekly 5 = 2-4 x/week 6 = 5-6 x/week 7 = Daily -1 = N/A

Column ‘C’ ResponsE Where and by Whom 1 = On-site by project staff 2 = On-site by another agency 3 = Off-site by project staff 4 = Off-site by another agency 5 = On-site by parent organization staff 6 = Off-site by parent organization staff -1 = N/A

Column ‘D’ ResponsE role of referring party 1 = Primary Care Provider 2 = Nurse 3 = Case Manager 4 = Social Worker 5 = Counselor 6 = Other -8 = Don’t know

In the following section, choose the response category that most closely describes the services received by this client. Record the corresponding value in the box for each column: A – Services Received, B – Number of Sessions, and C – Where and by Whom. Please note for Column C you can enter more than one number as appropriate for where services were received. D – Role of Referring Party.

If a client is given a N/A for receiving a service in Column A, then it is anticipated that the client will also receive N/A in Columns B-D.

Intimate Partner Violence (IPV) REFERRAL ACTIVITY
	A Services Received	B Sessions	C Where and by Whom	D Role of Referring
Domestic Violence Shelter	|___| DF_RA40_A	|___| DF_RA40_B	|___| DF_RA40_C	|___| DF_RA40_D
Legal	|___| DF_RA41_A	|___| DF_RA41_B	|___| DF_RA41_C	|___| DF_RA41_D
Transportation	|___| DF_RA42_A	|___| DF_RA42_B	|___| DF_RA42_C	|___| DF_RA42_D
Advocacy	|___| DF_RA43_A	|___| DF_RA43_B	|___| DF_RA43_C	|___| DF_RA43_D
Family Counseling	|___| DF_RA44_A	|___| DF_RA44_B	|___| DF_RA44_C	|___| DF_RA44_D
Law Enforcement	|___| DF_RA45_A	|___| DF_RA45_B	|___| DF_RA45_C	|___| DF_RA45_D
Court/Judicial	|___| DF_RA46_A	|___| DF_RA46_B	|___| DF_RA46_C	|___| DF_RA46_D
Faith-based	|___| DF_RA47_A	|___| DF_RA47_B	|___| DF_RA47_C	|___| DF_RA47_D
Medical Services	|___| DF_RA48_A	|___| DF_RA48_B	|___| DF_RA48_C	|___| DF_RA48_D
Support group	|___| DF_RA49_C	|___| DF_RA49_C	|___| DF_RA49_C	|___| DF_RA49_D
Traditional/Indigenous Healers	|___| DF_RA50_C	|___| DF_RA50_C	|___| DF_RA50_C	|___| DF_RA50_D

IPV REFERRAL ACTIVITY (continued)

51. Number of referrals made in last 30 days _________

52. If the client was referred to IPV services, did the client confirm the referral?

 Yes  No

53. If the client was referred to IPV services, did the client complete the referral?

 Yes  No

54. Please check which method(s) and the processes used to refer clients.

 Verbal (tell them where to go)

• Issue standard referral form

 Blank paper to write referral

Information

 Telephone referral

 Escort client

 Other: ___________________

55. How many referral follow-ups were conducted for each category listed below?

Verbal ______

Issue standard referral form ______

Blank paper to write referral Information _____

Telephone referral ______

Escort client ______

Other: ______

56. Regardless of referral method(s), what type of support was provided to ensure the client confirmed their referral?

• Incentives (e.g., transit subsidy)

  • How often: ______

  • How notified:  Verbal  Written  Text  Telephonic  Email

• Language Interpreter

  • How often: ______

  • How notified:  Verbal  Written  Text  Telephonic  Email

• List of needed referral documentation

  • How often: ______

  • How notified:  Verbal  Written  Text  Telephonic  Email

• Information about organization referred to

  • How often: ______

  • How notified:  Verbal  Written  Text  Telephonic  Email

• Reminders

  • How often: ______

  • How notified:  Verbal  Written  Text  Telephonic  Email

57. Regardless of referral method(s), what type of support was provided to ensure the client completed the referral?

• Transportation/Transportation Subsidy

  • How often: ______

  • How notified:  Verbal  Written  Text  Telephonic  Email

• Language Interpreter

  • How often: ______

  • How notified:  Verbal  Written  Text  Telephonic  Email

• List of needed referral documentation

  • How often: ______

  • How notified:  Verbal  Written  Text  Telephonic  Email

• Information about organization referred to

  • How often: ______

  • How notified:  Verbal  Written  Text  Telephonic  Email

• Reminders

  • How often: ______

  • How notified:  Verbal  Written  Text  Telephonic  Email

58. Was the client ever referred back to your organization or facility for follow-up after referral services were received?

 Yes  No

If so, how many times? How often: ______