Child Combined Too Child Combined Tool

OMB No. 0930-0285

Expiration Date 11/30/2013

Transformation Accountability (TRAC)

Center for Mental Health Services

NOMs Client-Level Measures for Discretionary Programs Providing Direct Services

SERVICES TOOL

Child/Adolescent or Caregiver

Combined Respondent Version

March 2013

Version 10

Public reporting burden for this collection of information is estimated to average 30 minutes per response if all items are asked of a consumer/participant; to the extent that providers already obtain much of this information as part of their ongoing consumer/participant intake or follow-up, less time will be required. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 2-1057, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0285.

RECORD MANAGEMENT

[RECORD MANAGEMENT IS REPORTED BY GRANTEE STAFF AT BASELINE, REASSESSMENT AND DISCHARGE REGARDLESS OF WHETHER AN INTERVIEW IS CONDUCTED.]

Consumer ID |____|____|____|____|____|____|____|____|____|____|____|

Grant ID (Grant/Contract/Cooperative Agreement) |____|____|____|____|____|____|____|____|____|____|

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

1. Indicate Assessment Type:

Baseline	Reassessment	Clinical Discharge
[ENTER THE MONTH AND YEAR WHEN THE CONSUMER FIRST RECEIVED SERVICES UNDER THE GRANT FOR THIS EPISODE OF CARE.]	Which 6-month reassessment? |____|____|
|____|____| /  |____|____|____|____| MONTH                YEAR	[ENTER 06 FOR A 6-MONTH, 12 FOR A 12-MONTH, 18 FOR AN 18-MONTH ASSESSMENT, ETC.]

2. Was the interview conducted?

 Yes When? |____|____| / |____|____| / |____|____|____|____| MONTH DAY YEAR

 No Why not? Choose only one. Not able to obtain consent from proxy  Consumer was impaired or unable to provide consent  Consumer refused this interview only  Consumer was not reached for interview  Consumer refused all interviews [GO TO THE INSTRUCTIONS BELOW QUESTION 3.]

3. Was the respondent the child or the caregiver?

• Child [Prefer CHILD Age 11 and older]

• Caregiver

[IF this is a BASELINE, go TO SECTION a.]

[For all reassessments:

if an INTERVIEW was conducted, go TO SECTION B.

IF an INTERVIEW WAS NOT CONDUCTED, go TO SECTION I.]

[for A clinical discharge:

if an INTERVIEW was conducted, go TO SECTION B.

IF an INTERVIEW WAS NOT CONDUCTED, go TO SECTION J.]

1. DEMOGRAPHIC DATA

[Section A is ONLY COLLECTED AT baseline. IF THIS IS NOT a baseline, GO TO SECTION B.]

1. What is your [child’s] gender?

 MALE

 FEMALE

 TRANSGENDER

 OTHER (SPECIFY) _____________________________________

 REFUSED

2. Are you [Is your child] Hispanic or Latino?

 YES

 NO [GO TO 3.]

 REFUSED [GO TO 3.]

[IF YES] What ethnic group do you consider yourself [your child]? Please answer yes or no for each of the following. You may say yes to more than one.

	Yes	No	REFUSED
Central American			
Cuban			
Dominican			
Mexican			
Puerto Rican			
South American			
OTHER			 [IF YES, SPECIFY BELOW.]
(SPECIFY) __________________________________

3. What race do you consider yourself [your child]? Please answer yes or no for each of the following. You

may say yes to more than one.

	Yes	No	REFUSED
Alaska Native			
American Indian			
Asian			
Black or Afican American			
Native Hawaiian or Other Pacific Islander			
White			

4. What is your [your child’s] month and year of birth?

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

MONTH YEAR  REFUSED

[STOP HERE IF THE BASELINE INTERVIEW WAS NOT CONDUCTED. ALL OTHERS CONTINUE TO SECTION B.]

B. FUNCTIONING

1. How would you rate your [your child’s] overall health right now?

 Excellent

 Very Good

 Good

 Fair

 Poor

 REFUSED

 DON’T KNOW

2. In order to provide the best possible mental health and related services, we need to know what you think about how well you were [your child was] able to deal with everyday life during the past 30 days. Please indicate your disagreement/agreement with each of the following statements.

[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER (CAREGIVER).]

STATEMENT	RESPONSE OPTIONS
	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree	Refused	Not Applicable
a. I am [my child is] handling daily life.						
b. I get [my child gets] along with family members.							
c. I get [my child gets] along with friends and other people.						
d. I am [my child is] doing well in school and/or work.							
e. I am [my child is] able to cope when things go wrong.						
f. I am satisfied with our family life right now.						

B. FUNCTIONING (Continued)

[IF the caregiver is the rEspondent, GO to the optional GAF Question.]

3. The following questions ask about how you have been feeling during the past 30 days. For each question, please indicate how often you had this feeling.

[READ EACH question FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]

QUESTION	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	REFUSED	DON’T KNOW
a. nervous?							
b. hopeless?							
c. restless or fidgety?							
d. so depressed that nothing could cheer you up?							
e. that everything was an effort?							
f. worthless?							

B. FUNCTIONING (Continued)

[IF the caregiver is the rEspondent, GO TO THE optional GAF QUESTION.]

4. The following questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances we’ll talk about are prescribed by a doctor (like pain medications). But I will only record those if you have taken them for reasons or in doses other than prescribed.

[READ EACH question FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]

QUESTION	RESPONSE OPTIONS
In the past 30 days, how often have you used…	Never	Once or Twice	Weekly	Daily or Almost Daily	REFUSED	DON’T KNOW
a. tobacco products (cigarettes, chewing tobacco, cigars, etc.)?						
b. alcoholic beverages (beer, wine, liquor, etc.)?						
b1. [IF b >= ONCE OR TWICE, AND RESPONDENT MALE], How many times in the past 30 days have you had five or more drinks in a day? [CLARIFY IF NEEDED: A standard alcoholic beverage (e.g., 12 oz beer, 5 oz wine, 1.5 oz liquor)].						
b2. [IF b >= ONCE OR TWICE, AND RESPONDENT NOT MALE], How many times in the past 30 days have you had four or more drinks in a day? [CLARIFY IF NEEDED: A standard alcoholic beverage (e.g., 12 oz beer, 5 oz wine, 1.5 oz liquor)].						
c. cannabis (marijuana, pot, grass, hash, etc.)?						
d. cocaine (coke, crack, etc.)?						
e. prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)?						
f. methamphetamine (speed, crystal meth, ice, etc.)?						
g. inhalants (nitrous oxide, glue, gas, paint thinner, etc.)?						
h. sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, Rohypnol, GHB, etc.)?						
i. hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)?						
j. street opioids (heroin, opium, etc.)?						
k. prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?						
l. other – specify:						

B. FUNCTIONING (Continued)

[OPTIONAL: GAF SCORE REPORTED BY GRANTEE STAFF AT PROJECT’S DISCRETION.]

DATE GAF WAS ADMINISTERED: |____|____| / |____|____| /|____|____|____|____|

MONTH DAY YEAR

WHAT WAS THE CONSUMER’S SCORE? GAF = |____|____|____|

[OPTIONAL: CBCL TOTAL PROBLEMS T-SCORE REPORTED BY GRANTEE STAFF AT PROJECT’S DISCRETION.]

DATE CBCL WAS ADMINISTERED: |____|____| / |____|____| /|____|____|____|____|

MONTH DAY YEAR

WHAT WAS THE CONSUMER’S SCORE? TOTAL PROBLEMS T-SCORE = |____|____|____|

B. MILITARY FAMILY AND DEPLOYMENT

[QUESTION 5 IS NOT APPLICABLE TO CHILD PROGRAMS.]

[QUESTION 6 IS ONLY ASKED AT BASELINE. IF THIS IS NOT A BASELINE, SKIP TO SECTION C.]

6. Is anyone in your [your child’s] family or someone close to you [your child] currently serving on active duty in or retired/separated from the Armed Forces, the Reserves, or the National Guard?  

• Yes, only one person

• Yes, more than one person

• No

• REFUSED

C. STABILITY IN HOUSING

1. In the past 30 days how many …	Number of Nights/ Times	REFUSED	DON’T KNOW
a. nights have you [has your child] been homeless?	|____|____|		
b. nights have you [has your child] spent in a hospital for mental health care?	|____|____|		
c. nights have you [has your child] spent in a facility for detox/inpatient or residential substance abuse treatment?	|____|____|		
d. nights have you [has your child] spent in correctional facility including juvenile detention, jail, or prison?	|____|____|		
[add up the total number of nights spent homeless, in hospital for mental health care, in detox/inpatient or residential substance abuse treatment, or in a correctional facility. (items a-d, cannot exceed 30 nights).]	|____|____|
e. times have you [has your child] gone to an emergency room for a psychiatric or emotional problem?	|____|____|		

[if 1a, 1b, 1c, or 1d IS 16 or more nights, GO to Section d.]

2. In the past 30 days, where have you [has your child] been living most of the time?

[DO NOT READ RESPONSE OPTIONS to consumer (caregiver). SELECT ONLY ONE.]

• CAREGIVER’S OWNED OR RENTED HOUSE, APARTMENT, TRAILER, OR ROOM

• INDEPENDENT OWNED OR RENTED HOUSE, APARTMENT, TRAILER OR ROOM

• SOMEONE ELSE’S HOUSE, APARTMENT, TRAILER, OR ROOM

• HOMELESS (SHELTER, STREET/OUTDOORS, PARK)

• GROUP HOME

• FOSTER CARE (SPECIALIZED THERAPEUTIC TREATMENT)

• TRANSITIONAL LIVING FACILITY

• HOSPITAL (MEDICAL)

• HOSPITAL (PSYCHIATRIC)

• DETOX/INPATIENT OR RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY

• CORRECTIONAL FACILITY (JUVENILE DETENTION CENTER/JAIL/PRISON)

• OTHER HOUSED (SPECIFY) _______________________________________________

• REFUSED

• DON’T KNOW

D. EDUCATION

1. During the past 30 days of school, how many days were you [was your child] absent for any reason?

• 0 DAYS

• 1 DAY

• 2 DAYS

• 3 TO 5 DAYS

• 6 TO 10 DAYS

• MORE THAN 10 DAYS

• REFUSED

• DON’T KNOW

• NOT APPLICABLE

a. [IF ABSENT], how many days were unexcused absences?

• 0 DAYS

• 1 DAY

• 2 DAYS

• 3 TO 5 DAYS

• 6 TO 10 DAYS

• MORE THAN 10 DAYS

• REFUSED

• DON’T KNOW

• NOT APPLICABLE

2. What is the highest level of education you have (your child has) finished, whether or not you (he/she has) received a degree?

• NEVER ATTENDED

• PRESCHOOL

• KINDERGARTEN

• 1^ST GRADE

• 2^ND GRADE

• 3^RD GRADE

• 4^TH GRADE

• 5^TH GRADE

• 6^TH GRADE

• 7^TH GRADE

• 8^TH GRADE

• 9^TH GRADE

• 10^TH GRADE

• 11^TH GRADE

• 12^TH GRADE/HIGH SCHOOL DIPLOMA/EQUIVALENT (GED)

• VOC/TECH DIPLOMA

• SOME COLLEGE OR UNIVERSITY

• REFUSED

• DON’T KNOW

E. CRIME AND CRIMINAL JUSTICE STATUS

1. In the past 30 days, how many times have you [has your child] been arrested?

|____|____| TIMES  REFUSED  DON’T KNOW

[IF THIS IS A baseline, GO TO SECTION G. OTHERWISE, GO TO SECTION F.]

F. PERCEPTION OF CARE

[SECTION F IS NOT COLLECTED AT baseline. FOR baseline INTERVIEWS, Go TO SECTION G.]

1. In order to provide the best possible mental health and related services, we need to know what you think about the services you [your child] received during the past 30 days, the people who provided it, and the results. Please indicate your disagreement/agreement with each of the following statements.

[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER (CAREGIVER).]

STATEMENT	RESPONSE OPTIONS
	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree	Refused
a. Staff here treated me with respect.						
b. Staff respected my family’s religious/spiritual beliefs.						
c. Staff spoke with me in a way that I understood.						
d. Staff was sensitive to my cultural/ethnic background.						
e. I helped choose my [my child’s] services.						
f. I helped to choose my [my child’s] treatment goals.						
g. I participated in my [my child’s] treatment.						
h. Overall, I am satisfied with the services I [my child] received.						
i. The people helping me [my child] stuck with me [us] no matter what.						
j. I felt I had [my child had] someone to talk to when I [he/she] was troubled.						
k. The services I [my child and/or family] received were right for me [us].						
l. I [my family] got the help I [we] wanted [for my child].						
m. I [my family] got as much help as I [we] needed [for my child].						

F. PERCEPTION OF CARE (Continued)

2. [INDICATE WHO ADMINISTERED SECTION F - PERCEPTION OF CARE TO THE CONSUMER (CAregiver) FOR THIS INTERVIEW.]

Administrative Staff

Care Coordinator

CASE MANAGER

Clinician Providing direct Services

CLINICIAN NOT PROVIDING SERVICES

CONSUMER PEER

DATA COLLECTOR

evaluatoR

FAMILY ADVOCATE

RESEARCH ASSISTANT STAFF

SELF-ADMINISTERED

OTHER (SPECIFY) ____________________________

G. SOCIAL CONNECTEDNESS

1. Please indicate your disagreement/agreement with each of the following statements. Please answer for relationships with persons other than your [your child’s] mental health provider(s) over the past 30 days.

[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER (CAREGIVER).]

STATEMENT	RESPONSE OPTIONS
	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree	REFUSED
a. I know people who will listen and understand me when I need to talk.						
b. I have people that I am comfortable talking with about my [my child’s] problems.						
c. In a crisis, I would have the support I need from family or friends.						
d. I have people with whom I can do enjoyable things.						

[IF THIS IS a baseline, STOP NOW. THE INTERVIEW IS COMPLETE.]

[IF THIS IS A reassessment INTERVIEW, GO TO SECTION I.]

[IF THIS IS A CLINICAL DISCHARGE INTERVIEW, go to SECTION J.]

H. program specific questions

Some programs have program specific data that is submitted to TRAC. CMHS will let you know if you are required to do Section H, and you will have a separate Section H form.

No child programs are required to collect data for section h at this time.

I. REASSESSMENT STATUS

[SECTION I IS REPORTED BY GRANTEE STAFF AT REASSESSMENT.]

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

 Yes

 No

2. Is the consumer still receiving services from your project?

 Yes

 No

[Go to section K.]

J. CLINICAL DISCHARGE STATUS

[SECTION J IS REPORTED BY GRANTEE STAFF ABOUT The CONSUMER AT CLINICAL DISCHARGE.]

1. On what date was the consumer discharged?

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

MONTH YEAR

2. What is the consumer’s discharge status?

 Mutually agreed cessation of treatment

Withdrew from/refused treatment

 No contact within 90 days of last encounter

• Clinically referred out

 Death

 Other (Specify) __________________________________

[Go to section K.]

K. SERVICES RECEIVED

[SECTION K IS REPORTED BY GRANTEE STAFF AT REASSESSMENT and DISCHARGE UNLESS the CONSUMER REFUSED THIS INTERVIEW OR ALL INTERVIEWS, IN WHICH CASE IT IS OPTIONAL.]

1. On what date did the consumer last receive services?

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

MONTH YEAR

[IDENTIFY ALL OF THE SERVICES YOUR PROJECT PROVIDED TO THE CONSUMER SINCE HIS/HER LAST NOMs INTERVIEW; THIS INCLUDES CMHS-FUNDED AND NON-FUNDED SERVICES.]

Core Services	Provided		UNKNOWN	SERVICE NOT AVAILABLE
	Yes	No
1. Screening				
2. Assessment				
3. Treatment Planning or Review				
4. Psychopharmacological Services				
5. Mental Health Services				

[IF the answer TO 5 ‘MENTAL HEALTH SERVICES’ IS YES, PLEASE ESTIMATE HOW FREQUENTLY MENTAL HEALTH SERVICES WERE DELIVERED.]

Number of times ______ per  Day UNKNOWN

 Week 

 Month

 Year

	Yes	No	UNKNOWN	SERVICE NOT AVAILABLE
6. Co-Occurring Services				
7. Case Management				
8. Trauma-specific Services				
9. Was the Consumer referred to another provider for any of the above core services?			

Support Services	Provided		UNKNOWN	SERVICE NOT AVAILABLE
	Yes	No
1. Medical Care				
2. Employment Services				
3. Family Services				
4. Child Care				
5. Transportation				
6. Education Services				
7. Housing Support				
8. Social Recreational Activities				
9. Consumer Operated Services				
10. HIV Testing				
11. Was the Consumer referred to another provider for any of the above support services?			