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
Teen Survey
Client Identifier: __________________________________________
Date: _____________________

Pre or Post Evaluation (circle one)

Instructions: Circle the answer that most accurately describes how you feel about each of the five
questions below.
1.

How comfortable are you talking about using or not using drugs/alcohol/tobacco?

Completely
uncomfortable

2.

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 confident do you feel identifying triggers and cravings for drugs/alcohol/tobacco?

Completely
uncomfortable

5.

Moderately
comfortable

How confident are you that you have 2 ways to turn down drugs/alcohol/tobacco if you
wanted to?

Completely
uncomfortable

4.

Slightly
uncomfortable

How comfortable are you with being open about the positives and negatives of using
drugs/alcohol/tobacco?

Completely
uncomfortable

3.

Moderately
uncomfortable

Moderately
uncomfortable

Slightly
uncomfortable

Moderately
comfortable

Slightly
comfortable

Completely
comfortable

How confident are you that you know how drugs/alcohol/tobacco could affect your mental
health?

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

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

Instructions: Circle Yes or No for each of the five questions below:

6.

Are you aware of alternatives to using drugs/alcohol/tobacco that would give you those same
positive affects?
Yes

7.

Are you able to identify at least 2 reasons to not use drugs/alcohol/tobacco?
Yes

8.

No

N/A

Can you identify people in your life who are supportive of you not using
drugs/alcohol/tobacco, someone who is good at coming up with new ideas and alternatives to
not using drugs/alcohol/tobacco, and someone who listens and is understanding.
Yes

10.

No

Can you identify and apply the 5 Step decision making process in situations that involve
drugs/alcohol/tobacco?
Yes

9.

No

No

Are you aware of the rules in your family around drug/alcohol/tobacco?
Yes

No

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