Surveys to Inform Service Delivery Improvement of Teen Intervene Curriculum with Mental Health Providers and Adolescent Clients

OMB No. 0990-0379
Exp. Date 09/30/2020

Teen Intervene Pre and Post-Workshop Survey for Mental Health
Providers
Instructions: Circle the answer that most accurately describes how you feel about each of the
ten questions below.
Circle one: Pre-Worksop
1.

How confident are you in your ability to competently utilize screening tools for a client’s
use of drugs/alcohol/tobacco?

Completely
uncomfortable

2.

Moderately
comfortable

Slightly
comfortable

Completely
comfortable

Moderately
uncomfortable

Slightly
uncomfortable

Moderately
comfortable

Slightly
comfortable

Completely
comfortable

Moderately
uncomfortable

Slightly
uncomfortable

Moderately
comfortable

Slightly
comfortable

Completely
comfortable

Teen Intervene includes Screening, the actual Brief Intervention, and referral. How
comfortable are you in competently evaluating a client’s readiness for change?

Completely
uncomfortable

5.

Slightly
uncomfortable

Providing this service in a culturally sensitive and trauma informed manner is extremely
important. How comfortable are you with listening and assisting a young person to talk
honestly about their use of drugs/alcohol/tobacco?

Completely
uncomfortable

4.

Moderately
uncomfortable

Following screening, how confident are you in determining whether or not to proceed
with Teen Intervene or to refer to further assessment?

Completely
uncomfortable

3.

Post Workshop

Moderately
uncomfortable

Slightly
uncomfortable

Moderately
comfortable

Slightly
comfortable

Completely
comfortable

Distinguishing the pros and cons of substance use occurs in Teen Session 1. How
comfortable are you with listening and encouraging teens to freely talk about the
positives and negatives of using and/or changing their drug/alcohol/tobacco use?

Completely
uncomfortable

Moderately
uncomfortable

Slightly
uncomfortable

Moderately
comfortable

Slightly
comfortable

Completely
comfortable

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete
this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services,
OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

OMB No. 0990-0379
Exp. Date 09/30/2020

6.

How comfortable are you in your ability to competently identify internal and external
triggers and cravings for the use of drugs/alcohol/tobacco?

Completely
uncomfortable

7.

Slightly
comfortable

Completely
comfortable

Moderately
uncomfortable

Slightly
uncomfortable

Moderately
comfortable

Slightly
comfortable

Completely
comfortable

Moderately
uncomfortable

Slightly
uncomfortable

Moderately
comfortable

Slightly
comfortable

Completely
comfortable

How comfortable are you in your competency to assist a teen to explore and build their
social support systems?

Completely
uncomfortable

10.

Moderately
comfortable

Enhancing decision making skills can be helpful for teens in a variety of situations,
including substance use. How comfortable are you with explaining the 5 Step Plan (stop,
think, choose, act, and evaluate) for enhancing decision making?

Completely
uncomfortable

9.

Slightly
uncomfortable

How comfortable do you feel in assisting a teen to respond to opportunities for
drug/alcohol/tobacco use and peer pressure?

Completely
uncomfortable

8.

Moderately
uncomfortable

Moderately
uncomfortable

Slightly
uncomfortable

Moderately
comfortable

Slightly
comfortable

Completely
comfortable

Family involvement is important for Teen Intervene success. How comfortable are you
in involving families in the program?

Completely
uncomfortable

Moderately
uncomfortable

Slightly
uncomfortable

Moderately
comfortable

Slightly
comfortable

Completely
comfortable