CSAT GPRA Client
Outcome
Measures for Discretionary Programs
FINAL
DRAFT
Public reporting burden for this collection of information is estimated to average 36 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information, if all items are asked of a client/participant; to the extent that providers already obtain much of this information as part of their ongoing client/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 15E57A, 5600 Fishers Lane, 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 0930-0208.
Client ID |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
Client Description by Grant Type:
Treatment
grant client
Client
in recovery grant
Contract/Grant ID |____|____|____|____|____|____|____|____|____|____|
Interview Type [CIRCLE ONLY ONE TYPE.]
Intake [GO TO INTERVIEW DATE.]
3-month follow-up → → → Did you conduct a
follow-up interview?
Yes
No
[IF NO, GO DIRECTLY TO SECTION I.]
6-month follow-up → → → Did you
conduct a follow-up interview?
Yes
No
[IF NO, GO DIRECTLY TO SECTION I.]
Discharge → → → Did you conduct a
discharge interview?
Yes
No
[IF NO, GO DIRECTLY TO SECTION J.]
Interview
Date |____|____| / |____|____| /
|____|____|____|____|
Month Day Year
What is your birth month and year?
|____|____| / |____|____|____|____|
Month Year
Refused
What do you consider yourself to be??
Male
Female
Transgender
(Male to Female)
Transgender
(Female to Male)
Gender
non-conforming
Other
(Specify)______________________________
Are you Hispanic, Latino/a, or Spanish origin?
Yes
No
[SKIP TO QUESTION 4]
Refused
[SKIP TO QUESTION 4]
[IF YES] What ethnic group do you consider yourself? You may indicate more than one.
Central
American
Cuban
Dominican
Mexican
Puerto Rican
South American
Other (Specify)_____________
Refused
What is your race? You may indicate more than one.
Black or African American
White
American Indian
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other (Specify)_____________
Refused
Do you speak a language other than English at home?
Yes
No
IF YES, what is this language?
Spanish
Other ___________
Do you think of yourself as…
Straight
Or Heterosexual
Homosexual
(Gay Or Lesbian)
Bisexual
Queer,
Pansexual, And/Or Questioning
Asexual
Something
Else? Please Specify ___________________________________
Refused
What is your relationship status?
Married
Single
Divorced
Separated
Widowed
In
a relationship
In
multiple relationships
Refused
[IF NOT MALE] Are you currently pregnant?
Yes
No
Do
not know
Refused
Do you have children? [Refers to children both living and/or who may have died]
Yes
No
[SKIP TO QUESTION 10]
Refused
[SKIP TO QUESTION 10]
a. How many children under the age of 18 do you have?
|____|____|
Refused
b. Are any of your children, who are under the age of 18, living with someone else due to a court’s intervention?
Yes
Number of children removed from client’s care
|____|____|
No
[SKIP TO QUESTION 10]
Refused
[SKIP TO QUESTION 10]
c. Have you been reunited with any of your children, under the age of 18, who have been previously removed from your care? [THE VALUE IN ITEM C8c CANNOT EXCEED THE VALUE IN C8a.]
Yes
Number of children with whom the client has been reunited
|____|____|
No
Refused
Have you ever served in the Armed Forces, in the Reserves, in the National Guard, or in other Uniformed Services? [IF SERVED] What area, the Armed Forces, Reserves, National Guard, or other did you serve?
No
Yes,
In The Armed Forces
Yes,
In The Reserves
Yes,
In The National Guard
Yes,
Other Uniformed Services [Includes NOAA, USPHS]
11. How long does it take you, on average, to travel to the location where you receive services provided by this grant?
Half
an hour or less
Between
half an hour and one hour
Between
one hour and one and a half hours
Between
one and a half hours and two hours
Two
hours or more
Refused
1. Using the table below, please indicate the following:
The number of days, in the past 30 days, that the client reports using a substance.
The client should be encouraged to list the substances on their own. If they are unsure, the list from the table below can be read to the client. Please note that not all substance use is considered harmful or illicit – it may be that a substance is prescribed by a licensed provider, or that the client uses the substance in accordance with official, national safety guidelines. In such instances, clarification from the client should be sought, but if the substance is only taken as prescribed or used on each occasion in accordance with official, national safety guidelines, then it is not considered misuse. If no use of a listed substance is reported, please enter a zero (‘0’) in the corresponding ‘Number of Days Used’ column.
The route by which the substance is used.
Mark one route only. But, if the client identifies more than one route, choose the corresponding route with the highest associated number value (numbers 1 – 6). Responses should capture the past 30 days of use.
During the past 30 days, how many days have you used any of the following, and how do you take the substance?
|
Number of Days Used |
Route |
|||
1. Oral |
2. Intranasal |
3. Vaping |
|||
4. Smoking |
5. Non-IV Injection |
6. Intravenous (IV) Injection |
|||
0. |
|||||
Alcohol |
|
|
|||
Alcohol |
|___|___| |
|___| |
|||
Other (Specify) |
|___|___| |
|___| |
|||
|
|
|
|||
Opioids |
|
|
|||
Heroin |
|___|___| |
|___| |
|||
Morphine |
|___|___| |
|___| |
|||
Fentanyl (Prescription Diversion Or Illicit Source) |
|___|___| |
|___| |
|||
Dilaudid |
|___|___| |
|___| |
|||
Demerol |
|___|___| |
|___| |
|||
Percocet |
|___|___| |
|___| |
|||
Codeine |
|___|___| |
|___| |
|||
Tylenol 2, 3, 4 |
|___|___| |
|___| |
|||
OxyContin/Oxycodone |
|___|___| |
|___| |
|||
Non-prescription methadone |
|___|___| |
|___| |
|||
Non-prescription buprenorphine |
|___|___| |
|___| |
|||
Other (Specify) |
|___|___| |
|___| |
|||
|
|
|
|||
Cannabis |
|
|
|||
Cannabis (Marijuana) |
|___|___| |
|___| |
|||
Synthetic Cannabinoids |
|___|___| |
|___| |
|||
Other (Specify) |
|___|___| |
|___| |
|||
|
|
|
|||
Sedative, Hypnotic, or Anxiolytics |
|
|
|||
Sedatives |
|___|___| |
|___| |
|||
Hypnotics |
|___|___| |
|___| |
|||
Barbiturates |
|___|___| |
|___| |
|||
Anxiolytics/Benzodiazepines |
|___|___| |
|___| |
|||
Other (Specify) |
|___|___| |
|___| |
|||
|
|
|
|||
Cocaine |
|
|
|||
Cocaine |
|___|___| |
|___| |
|||
Crack |
|___|___| |
|___| |
|||
Other (Specify) |
|___|___| |
|___| |
|||
|
|
|
|||
Other Stimulants |
|
|
|||
Methamphetamine |
|___|___| |
|___| |
|||
Stimulant medications |
|___|___| |
|___| |
|||
Other (Specify) |
|___|___| |
|___| |
|||
|
|
|
|||
Hallucinogens & Psychedelics |
|
|
|||
PCP |
|___|___| |
|___| |
|||
MDMA |
|___|___| |
|___| |
|||
LSD |
|___|___| |
|___| |
|||
Mushrooms |
|___|___| |
|___| |
|||
Mescaline |
|___|___| |
|___| |
|||
Salvia |
|___|___| |
|___| |
|||
DMT |
|___|___| |
|___| |
|||
Other (Specify) |
|___|___| |
|___| |
|||
|
|
|
|||
Inhalants |
|
|
|||
Inhalants |
|___|___| |
|___| |
|||
Other (Specify) |
|___|___| |
|___| |
|||
|
|
|
|||
Other Psychoactive Substances |
|
|
|||
Non-prescription GHB |
|___|___| |
|___| |
|||
Ketamine |
|___|___| |
|___| |
|||
MDPV/Bath Salts |
|___|___| |
|___| |
|||
Kratom |
|___|___| |
|___| |
|||
Khat |
|___|___| |
|___| |
|||
Other tranquilizers |
|___|___| |
|___| |
|||
Other downers |
|___|___| |
|___| |
|||
Other sedatives |
|___|___| |
|___| |
|||
Other hypnotics |
|___|___| |
|___| |
|||
Other (Specify) |
|___|___| |
|___| |
|||
|
|
|
|||
Tobacco and Nicotine |
|
|
|||
Tobacco |
|___|___| |
|___| |
|||
Nicotine (Including Vape Products) |
|___|___| |
|___| |
|||
Other (Specify) |
|___|___| |
|___| |
|||
|
|
|
If you have been diagnosed with an alcohol use disorder, which FDA-approved medication did you receive for the treatment of this alcohol use disorder in the past 30 days? [CHECK ALL THAT APPLY.]
Naltrexone [IF
RECEIVED] Specify how many days received |___|___|
Extended‒release Naltrexone [IF
RECEIVED] Specify how many doses received |___|___|
Disulfiram [IF
RECEIVED] Specify how many days received |___|___|
Acamprosate [IF
RECEIVED] Specify how many days received |___|___|
Did not receive an FDA-approved medication for a diagnosed alcohol
use disorder
Client does not report such a diagnosis
If you have been diagnosed with an opioid use disorder, which FDA-approved medication did you receive for the treatment of this opioid use disorder in the past 30 days? [CHECK ALL THAT APPLY.]
Methadone [IF
RECEIVED] Specify how many days received |___|___|
Buprenorphine [IF
RECEIVED] Specify how many days received |___|___|
Naltrexone
[IF RECEIVED] Specify how many days received
|___|___|
Extended‒release Naltrexone [IF
RECEIVED] Specify how many doses received |___|___|
Did not receive an FDA-approved medication for a diagnosed opioid
use disorder
Client does not report such a diagnosis
If you have been diagnosed with a stimulant use disorder, which evidence-based interventions did you receive for the treatment of this disorder in the past 30 days?
Contingency Management [IF
RECEIVED] Specify how many days received |___|___|
Community Reinforcement [IF
RECEIVED] Specify how many days received |___|___|
Cognitive Behavioral Therapy [IF
RECEIVED] Specify how many days received |___|___|
Other evidence-based intervention [IF
RECEIVED] Specify how many days received |___|___|
Did not receive any intervention for a diagnosed stimulant use
disorder
Client does not report such a diagnosis
If you have been diagnosed with a tobacco use disorder, which FDA-approved medication did you receive for the treatment of this tobacco use disorder in the past 30 days? [CHECK ALL THAT APPLY.]
Nicotine Replacement [IF
RECEIVED] Specify how many days received |___|___|
Bupropion [IF
RECEIVED] Specify how many days received |___|___|
Varenicline [IF
RECEIVED] Specify how many days received |___|___|
Did not receive an FDA-approved medication for a diagnosed tobacco
use disorder
Client does not report such a diagnosis
In the past 30 days, did you experience an overdose or take too much of a substance that resulted in needing supervision or medical attention?
Yes [IF YES, SPECIFY BELOW, IN QUESTION 7]
No
[IF NO, MOVE TO QUESTION 8]
Refused
[MOVE TO QUESTION 8]
In the past 30 days, after taking too much of a substance or overdosing, what intervention did you receive? You may indicate more than one.
Naloxone (Narcan)
Care in an Emergency Department
Care from a Primary Care Provider
Admission to a hospital
Supervision by someone else
Other (Specify) ______________________________
Refused
Not including this current episode, how many times in your life have you been treated at an inpatient or outpatient facility for a substance use disorder?
One time
Two times
Three times
Four times
Five times
Six or more times
Never [SKIP TO QUESTION 10]
Refused [SKIP TO QUESTION 10]
Approximately when was the last time you received inpatient or outpatient treatment for a substance use disorder?
Less than 6 months ago
Between 6 months and one year ago
One to two years ago
Two to three years ago
Three to four years ago
Five or more years ago
Refused
Have you ever been diagnosed with a mental health illness by a health care professional?
Yes
No
[SKIP TO QUESTION 11]
Refused
[SKIP TO QUESTION 11]
[IF YES] Please ask the client to self-report their mental health illnesses as listed in the table below. The client should be encouraged to report their own mental health illnesses but if preferred, the list can be read to the client.
Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders |
|
Brief psychotic disorder |
|
Delusional disorder |
|
Schizoaffective disorders |
|
Schizophrenia |
|
Schizotypal disorder |
|
Shared psychotic disorder |
|
Unspecified psychosis |
|
Mood [affective] disorders |
|
Bipolar disorder |
|
Major depressive disorder, recurrent |
|
Major depressive disorder, single episode |
|
Manic episode |
|
Persistent mood [affective] disorders |
|
Unspecified mood [affective] disorder |
|
Phobic Anxiety and Other Anxiety Disorders |
|
Agoraphobia without panic disorder |
|
Agoraphobia with panic disorder |
|
Agoraphobia, unspecified |
|
Generalized anxiety disorder |
|
Panic disorder |
|
Phobic anxiety disorders |
|
Social phobias (Social anxiety disorder) |
|
Specific (isolated) phobias |
|
Obsessive-compulsive disorders |
|
Excoriation (skin-picking) disorder |
|
Hoarding disorder |
|
Obsessive-compulsive disorder |
|
Obsessive-compulsive disorder with mixed obsessional thoughts and acts |
|
Reaction to severe stress and adjustment disorders |
|
Acute stress disorder; reaction to severe stress, and adjustment disorders |
|
Adjustment disorders |
|
Body dysmorphic disorder |
|
Dissociative and conversion disorders |
|
Dissociative identity disorder |
|
Post traumatic stress disorder |
|
Somatoform disorders |
|
Behavioral syndromes associated with physiological disturbances and physical factors |
|
Eating disorders |
|
Sleep disorders not due to a substance or known physiological condition |
|
Disorders of adult personality and behavior |
|
Antisocial personality disorder |
|
Avoidant personality disorder |
|
Borderline personality disorder |
|
Dependent personality disorder |
|
Histrionic personality disorder |
|
Intellectual disabilities |
|
Obsessive-compulsive personality disorder |
|
Other specific personality disorders |
|
Paranoid personality disorder |
|
Personality disorder, unspecified |
|
Pervasive and specific developmental disorders |
|
Schizoid personality disorder |
|
� NONE OF THE ABOVE
11. Was the client screened by your program, using an evidence-based tool or set of questions, for co-occurring mental health and/or substance use disorders?
Yes
No [SKIP
TO QUESTION 12]
11a. [IF YES] Did the client screen positive for
co-occurring mental health and substance use
disorders?
Yes
No
11b. [IF YES] Was the client referred for further assessment for a co-occurring mental health and
substance use disorder?
Yes
No
Identify the services you plan to provide to the client during the client’s course of treatment/recovery. [MARK ONLY THE CIRCLE CORRESPONDING TO THE PLANNED SERVICE THAT WILL BE PROVIDED UNDER THE CURRENT GRANT. MARK ALL THAT APPLY IN EACH SECTION.]
Modality
[SELECT AT LEAST ONE MODALITY.]
1. Case
Management
2. Intensive
Outpatient Treatment
3. Inpatient/Hospital
(Other Than Withdrawal Management)
4. Outpatient
Therapy
5. Outreach
6. Medication
A.
Methadone
C.
Naltrexone – Short Acting
D.
Naltrexone – Long Acting
E.
Disulfiram
F.
Acamprosate
G.
Nicotine Replacement
H.
Bupropion
I.
Varenicline
7. Residential/Rehabilitation
8. Withdrawal Management (Select Only One)
A. Hospital
Inpatient
B. Free
Standing Residential
C. Ambulatory
Detoxification
9. After
Care
10. Recovery
Support
11. Other
(Specify)
[SELECT AT LEAST ONE SERVICE.]
Treatment Services
[SBIRT GRANTS: You must PROVIDE at least one of the Treatment Services numbered 1 through 4.]
1. Screening
2. Brief
Intervention
3. Brief
Treatment
4. Referral
to Treatment
5. Assessment
6. Treatment
Planning
7. Recovery
Planning
8. Individual
Counseling
9. Group
Counseling
10. Contingency
Management
11. Community
Reinforcement
12. Cognitive
Behavioral Therapy
13. Family/Marriage
Counseling
14. Co-Occurring
Treatment Services
15. Pharmacological
Interventions
16. HIV/AIDS
Counseling
17. Cultural
Interventions/Activities
18. Other
Clinical Services
(Specify)
Case Management Services
1. Family
Services (E.g. Marriage Education, Parenting, Child Development
Services)
2. Child
Care
3. Employment Service
A. Pre-Employment
B. Employment
Coaching
4. Individual
Services Coordination
5. Transportation
6. HIV/AIDS Services
A.
If HIV Neg, Pre-Exposure Prophylaxis
B.
If HIV Neg, Post-Exposure Prophylaxis
C.
If HIV Positive, HIV Treatment
7. Transitional
Drug-Free Housing Services
8.
Housing Support
9. Health
Insurance Enrollment
10. Other
Case Management Services
(Specify)
Medical Services
1. Medical
Care
2. Alcohol/Drug
Testing
3. OB/GYN
Services
4. HIV/AIDS
Medical Support & Testing
5. Dental
Care
6. Viral
Hepatitis Medical Support & Testing
7. Other
STI Support & Testing
8. Other
Medical Services
(Specify)
After Care Services
1. Continuing
Care
2. Relapse
Prevention
3. Recovery
Coaching
4. Self-Help
and Mutual Support Groups
5. Spiritual
Support
6. Other
After Care Services
(Specify)
Education Services
1. Substance
Use Education
2. HIV/AIDS
Education
4.
Fentanyl Test Strip Training
5. Viral
Hepatitis Education
6. Other
STI Education Services
7. Other
Education Services
(Specify)
Recovery Support Services
1. Peer
Coaching or Mentoring
2. Vocational
Services
3. Recovery
Housing
4. Recovery
Planning
5.
Case Management Services to Specifically Support Recovery
6. Alcohol-
and Drug-Free Social Activities
7. Information
and Referral
8. Other
Recovery Support Services (Specify)_________________________
In the past 30 days, where have you been living most of the time? [DO NOT READ RESPONSE OPTIONS TO CLIENT.]
Shelter
(Safe Havens, Transitional Living Center [TLC], Low-Demand
Facilities, Reception Centers, Other Temporary Day or Evening
Facility)
Street/Outdoors
(Sidewalk, Doorway, Park, Public Or Abandoned Building)
Institution
(Hospital, Nursing Home, Jail/Prison)
Housed:
[IF HOUSED, CHECK APPROPRIATE SUBCATEGORY:]
Own/Rental
Apartment, Room, Trailer, Or House
Someone
Else’s Apartment, Room, Trailer, Or House (including couch
surfing)
Dormitory/College
Residence
Halfway
House or Transitional Housing
Residential
Treatment
Recovery
Residence/Sober Living
Other
Housed (Specify)
Refused
Do you currently live with any person who, over the past 30 days, has regularly used alcohol or other substances?
Yes
No
No,
lives alone
Refused
Are you currently enrolled in school or a job training program? [IF ENROLLED] Is that full time or part time? [IF CLIENT IS INCARCERATED, CODE D1 AS “NOT ENROLLED.”]
Not
Enrolled
Enrolled,
Full Time
Enrolled,
Part Time
Refused
What is the highest level of education you have finished, whether or not you received a degree?
Less
than 12th Grade
12th Grade/High School Diploma/Equivalent
Vocational/Technical
(Voc/Tech) Diploma
Some
College or University
Bachelor’s
Degree (For example: BA, BS)
Graduate
Work/Graduate Degree
Other
(Specify)____________________________________
Refused
Don’t Know
Are you currently employed? [CLARIFY BY FOCUSING ON STATUS DURING MOST OF THE PREVIOUS WEEK, DETERMINING WHETHER CLIENT WORKED AT ALL OR HAD A REGULAR JOB BUT WAS OFF WORK.] [IF CLIENT IS INCARCERATED AND HAS NO WORK OUTSIDE OF JAIL, CODE D3 AS “NOT LOOKING FOR WORK.”]
Employed,
Full Time (35+ Hours Per Week, Or Would Be, If Not For Leave or An
Excused Absence)
Employed,
Part Time
Unemployed—But
Looking For Work
Not
Employed, NOT Looking For Work
Not
working due to a disability
Retired,
not working
Other
(Specify)
Refused
4. Do you, individually, have enough money to pay for the following living expenses? Choose all that apply.
Food
Clothing
Transportation
Rent/Housing
Utilities
(Gas/Water/Electric)
Telephone
Connection (Cell or Landline)
Childcare
Health
Insurance
Refused
5. What is your personal annual income, meaning the total pre-tax income from all sources, earned in the past year?
$0
to $9,999
$10,000
to $14,999
$15,000
to $19,999
$20,000
to $34,999
$35,000
to $49,999
$50,000
to $74,999
$75,000
to $99,999
$100,000
to $199,999
$200,000
or more
Refused
In the past 30 days, how many times have you been arrested? [IF THE CLIENT INDICATES NO ARRESTS IN THE PAST 30 DAYS, BUT IS INCARCERATED AT THE TIME OF THE INTERVIEW, MARK CURRENTLY INCARCERATED]
|____|____|
times
Refused
Currently
Incarcerated
Are you currently awaiting charges, trial, or sentencing?
Yes
No
Refused
Are you currently on parole or probation or intensive pretrial supervision?
Probation
Parole
Intensive
Pretrial Supervision
No
Refused
Do you currently participate in a drug court program or are you in a deferred prosecution agreement?
Drug
court program
Deferred
prosecution agreement
No,
neither of these
Refused
1. How would you rate your quality of life over the past 30 days?
Very poor
Poor
Neither poor nor good
Good
Very good
Refused
2. In the past 30 days, how many days have you [ENTER ‘O’ IN DAYS FOR NO RESPONSE]:
Days Refused
a. Experienced
serious depression |____|____|
b. Experienced
serious anxiety or tension |____|____|
c. Experienced
hallucinations |____|____|
d. Experienced
trouble understanding, concentrating, or remembering |____|____|
e. Experienced
trouble controlling violent behavior |____|____|
f. Attempted
suicide |____|____|
g. Been
prescribed medication for psychological/emotional
problem |____|____|
[IF CLIENT REPORTS 1 OR MORE DAY TO ANY QUESTION IN #2, PLEASE ENSURE THAT THEY ARE SEEN BY A LICENSED PROFESSIONAL AS SOON AS POSSIBLE.]
3. How much have you been bothered by these psychological or emotional problems in the past 30 days?
Not
at all
Slightly
Moderately
Considerably
Extremely
Refused
No
reported mental health complaints in the past 30 days
4. In the past 30 days, where have you gone to receive medical care? You may select more than one response.
Primary
Care Provider
Urgent
Care
The
Emergency Department
A
specialist doctor
No
care was sought
Other
_____________________________
5. Do you currently have medical/health insurance?
Yes
No
[SKIP TO NEXT SECTION]
Refused
5a. [IF YES] What type of insurance do you have (Select all that apply)?
Medicare
Medicaid
Private Insurance or Employer Provided
TRICARE or other military health care
An assistance program [for example, a medication assistance
program]
Any other type of health insurance or health coverage plan
(Specify)______________________
Refused
In the past 30 days, did you attend any voluntary mutual support groups for recovery? In other words, did you participate in a non-professional, peer-operated organization that assists individuals who have addiction-related problems such as: Alcoholics Anonymous, Narcotics Anonymous, Secular Organization for Sobriety, Women for Sobriety, religious/faith-affiliated recovery mutual support groups, etc.? Attendance could have been in person or virtual.
Yes [IF
YES] Specify
How Many Times |____|____|
Refused
No
Refused
In the past 30 days, did you have interaction with family and/or friends that are supportive of your recovery?
Yes
No
Refused
How satisfied are you with your personal relationships?
Very
Dissatisfied
Dissatisfied
Neither
Satisfied nor Dissatisfied
Satisfied
Very
Satisfied
Refused
In the past 30 days did you realize that you need to change those social connections or places that negatively impact your recovery?
Yes
No
Refused
H1. PROGRAM SPECIFIC QUESTIONS
[QUESTION 1 SHOULD BE REPORTED BY GRANTEE STAFF AT FOLLOW-UP AND DISCHARGE]
Which of the following occurred for the client, subsequent to receiving treatment? [CHECK ALL THAT APPLY]
Client was reunited with child (or children)
[IF YES] With Agency Supervision
[OR] Without Agency Supervision
Client avoided out of home placement for child (or children)
None of the above
[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]
Did the [insert grantee name] help you obtain any of the following benefits? [CHECK ALL THAT APPLY]
Private Health Insurance
Medicaid
Medicare
SSI/SSDI
TANF
SNAP
Other (Specify)
None Of The Above
[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE.]
1. Have you achieved any of the following since you began receiving services or supports from [insert grantee name]? If yes, do you believe that the services you received from [insert grantee name] helped you with this achievement?
|
Achieved? |
If yes, do you believe that the services you received from [insert grantee name] helped you with this achievement? |
1a. Enrolled in school |
|
|
1b. Enrolled in vocational training |
|
|
1c. Currently employed
|
|
|
1d. Living in stable housing
|
|
|
[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]
Please indicate the degree to which you agree or disagree with the following statements:
a. Receiving treatment in a non-residential setting has enabled me to maintain parenting and family responsibilities while receiving treatment.
Strongly disagree
Disagree
Undecided
Agree
Strongly Agree
Refused
As a result of treatment, I feel I now have the skills and support to balance parenting and managing my recovery.
Strongly disagree
Disagree
Undecided
Agree
Strongly Agree
Refused
[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]
Please indicate the degree to which you agree or disagree with the following statements:
Receiving treatment in a residential setting without my child (or children) has enabled me to focus on my treatment without distractions of parenting and family responsibilities.
Strongly disagree
Disagree
Undecided
Agree
Strongly Agree
Refused
As a result of treatment, I feel I now have the skills and support to balance parenting and managing my recovery.
Strongly disagree
Disagree
Undecided
Agree
Strongly Agree
Refused
[QUESTION 1 SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOW-UP, AND DISCHARGE].
Please indicate which type of funding was/will be used to pay for the SBIRT services provided to this client. [CHECK ALL THAT APPLY.]
Current SAMHSA grant funding
Other federal grant funding
State funding
Client’s private insurance
Medicaid/Medicare
TRICARE
Other (Specify)____________________
[IF FOLLOW-UP OR DISCHARGE INTERVIEW, SKIP TO H3.]
[QUESTION 2 SHOULD BE REPORTED BY GRANTEE STAFF ONLY AT INTAKE/BASELINE]
If the client screened positive for substance misuse or a
substance use disorder, was the client assigned to the following
types of services? [IF CLIENT SCREENED
NEGATIVE, SELECT “NO” FOR EACH SERVICE BELOW]
Yes No
Brief Intervention Y N
Brief Treatment Y N
Referral to Treatment Y N
[QUESTION 3 SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE, BASELINE, FOLLOW-UP AND DISCHARGE]
Did the client receive the following types of services?
Yes No
Brief Intervention Y N
Brief Treatment Y N
Referral to Treatment Y N
[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT INTAKE/BASELINE, FOLLOW-UP AND DISCHARGE]
1. In the past 30 days, have you been sexually active?
Yes
No
[SKIP TO QUESTION 2.]
Not
Permitted To Ask [SKIP TO QUESTION 2.]
Refused
[SKIP TO QUESTION 2.]
[IF YES] Altogether, in the past 30 days, how many: Response Refused
a. Sexual
partners did you have?
Number: |____|____|____|
b. Did you engage in unprotected/condomless sex?
Yes
No → [SKIP TO QUESTION 2.]
c. [If yes] Were any of your partners:
1. Living
with HIV and not taking HIV medications
Yes
No
2. A
person who injects drugs
Yes
No
3. High
on one or more substances
Yes
No
2. Are you currently taking Pre-Exposure Prophylaxis (PrEP) for HIV prevention, or are you taking medication for the treatment of HIV?
PrEP
Treatment for HIV
Neither
Refused
Did the program provide access to the following?
A1. An HIV test?
Yes
No [SKIP TO 3B.1]
Refused [SKIP TO 3B.1]
A2. [IF YES] Was this the first time that you had been tested for HIV?
Yes
No [SKIP TO QUESTION A5]
Refused [SKIP TO QUESTION A5]
A3. [IF YES] Was HIV testing performed on-site or were you referred out for testing?
On-site [SKIP TO QUESTION A5]
Referred out
Refused [SKIP TO QUESTION A5]
A4. [IF REFFERED OUT FOR TESTING] Where was testing performed?
Primary Care Provider’s office
Dedicated clinic
VA Medical Center
Health Center or Community Clinic
Local Health Department
Specialty Addiction Treatment Program
Sexual Health Center
A mobile testing service
Other _________________
A5. What was the result?
Positive
Negative [SKIP TO A12]
Indeterminate
Refused [SKIP TO 3B.1]
A6. [IF POSITIVE OR INDETERMINATE] Did you receive confirmatory testing?
Yes
No [SKIP TO QUESTION A8]
Refused [SKIP TO QUESTION A8]
A7. [IF YES] What was the result?
Positive
Negative
Indeterminate
Refused
A8. Were you connected to HIV treatment services within 30 days of the positive test result?
Yes
No [SKIP TO QUESTION A10]
Refused [SKIP TO QUESTION A10]
A9. [IF YES] Where were you referred for ongoing treatment?
Primary Care Provider’s office
Dedicated clinic
VA Medical Center
Health Center or Community Clinic
Local Health Department
Specialty Addiction Treatment Program
Sexual Health Center
Other _________________
A10. Was rapid HIV testing offered to your substance-using and/or sexual partners?
Yes
No [SKIP TO QUESTION 3B.1]
Refused [SKIP TO QUESTION 3B.1]
A11. [IF YES] What was the number of drug-using and/or sexual partners offered HIV testing?
1
2
3
4 or more
Refused
A12. [IF NEGATIVE] Were you referred for Pre-Exposure Prophylaxis (PrEP) or Post-Exposure Prophylaxis (PEP), and/or were you referred for counseling about these interventions? (Select all that apply)
PrEP
PEP
Received Counseling
Did not receive medications
Did not receive counseling
Refused
B1. Did you receive a Rapid Hepatitis C (HCV) test
Yes
No [SKIP TO 3C.1]
Refused [SKIP TO 3C.1]
B2. [IF YES] Was this followed up with confirmatory Hepatitis C (HCV RNA) testing?
Yes
No [SKIP TO QUESTION B4]
B3. [IF YES] What was the result?
Positive
Negative [SKIP TO 3C.1]
Indeterminate
Refused [SKIP TO 3C.1]
B4. [IF SCREENED POSITIVE OR INDETERMINATE] Were you connected to Hepatitis C treatment
services?
Yes
No
Refused
C1. Hepatitis B (HBV) test?
Yes
No [SKIP TO 3D.1]
Refused [SKIP TO 3D.1]
C2. [IF YES] What was the result?
Positive
Negative [SKIP TO 3D.1]
Indeterminate
Refused [SKIP TO 3D.1]
C3. [IF SCREENED POSITIVE OR INDETERMINATE]
Were you connected to Hepatitis B treatment
services?
Yes
No
Refused
D1. Was the client offered a Hepatitis A and B Vaccination?
Yes [SKIP TO SECTION I OR J/K]
No
Refused [SKIP TO SECTION I OR J/K]
D2. [IF NO] Was the client referred out for vaccination?
Yes
No
Refused
1. Is peer support available at this program?
Yes [COMPLETE QUESTIONS 2 AND 3]
No [SKIP TO NEXT SECTION]
2. [IF YES] Have you achieved any of the following since you began receiving peer services from [insert grantee name]? If yes, do you believe that the services you received from [insert grantee name] helped you with this achievement?
|
Achieved? |
If yes, do you believe that the services you received from [insert grantee name] helped you with this achievement? |
1a. Enrolled in school |
|
|
1b. Enrolled in vocational training |
|
|
1c. Currently employed
|
|
|
1d. Living in stable housing |
|
|
To what extent has this program improved your quality of life?
To a great extent
Somewhat
Very little
Not at all
Refused
[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]
Please indicate the degree to which you agree or disagree with the following statements:
i. The use of technology accessed through [insert grantee name] has helped me communicate with my provider.
Strongly disagree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
Refused
ii. The use of technology accessed through [insert grantee name] has helped me reduce my substance use.
Strongly disagree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
Refused
iii. The use of technology accessed through [insert grantee name] has helped me manage my mental health symptoms.
Strongly disagree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
Refused
iv. The use of technology accessed through [insert grantee name] has helped me support my recovery.
Strongly disagree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
Refused
[QUESTIONS 1 AND 1A SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOW-UP, AND DISCHARGE]
[QUESTION 1B SHOULD BE REPORTED BY GRANTEE STAFF AT FOLLOW-UP/DISCHARGE IF THE CLIENT HAS BEEN REFERRED FOR SERVICES]
Did the client screen positive for, or have a history of, a mental health disorder?
Client screened positive
Client screened negative [SKIP TO QUESTION 2.]
Client was not screened [SKIP TO QUESTION 2.]
Client has a positive history
a. [IF POSITIVE] Was the client referred to mental health services?
Yes
No [SKIP TO H2.]
b. [IF YES] Did the client receive mental health services?
Yes
No
[QUESTIONS 2 AND 2A SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOW-UP, AND DISCHARGE]
[QUESTION 2B SHOULD BE REPORTED BY GRANTEE STAFF AT FOLLOW-UP/DISCHARGE IF THE CLIENT HAS BEEN REFERRED FOR SERVICES]
Did the client screen positive for, or have a history of, substance use disorder(s)?
Client screened positive
Client screened negative
Client was not screened
Client has a positive history
[IF THIS IS AN INTAKE/BASELINE AND THE RESPONSE IS NEGATIVE, NOT SCREENED, OR DON’T KNOW, SECTION H IS DONE. IF THIS IS A FOLLOW-UP OR DISCHARGE AND THE RESPONSE IS NEGATIVE, NOT SCREENED, OR DON’T KNOW, SKIP TO QUESTION 3]
a. [IF POSITIVE] Was the client referred to substance use disorder services?
Yes
No
b. [IF YES] Did the client receive substance use disorder services?
Yes
No
[IF THIS IS AN INTAKE/BASELINE, SECTION H IS DONE. IF THIS IS A FOLLOW-UP OR DISCHARGE AND THE RESPONSE IS NO OR DON’T KNOW, SKIP TO QUESTION 3]
[QUESTION 3 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]
Please indicate the degree to which you agree or disagree with the following statement: Receiving community-based services through [insert grantee name] has helped me to avoid further contact with the police and the criminal justice system.
Strongly disagree
Disagree
Undecided
Agree
Strongly Agree
Refused
THIS SECTION FOR SBIRT GRANTS ONLY [ITEMS TO BE REPORTED AT INTAKE/BASELINE].
1. When the SBIRT was administered, how did the client screen?
Negative
Positive
2. What was his/her screening score? AUDIT = |____|____|
CAGE = |____|____|
DAST = |____|____|
DAST-10 = |____|____|
NIAAA Guide = |____|____|
ASSIST/Alcohol Subscore = |____|____|
Other
(Specify) = |____|____|
______________________________________
______________________________________
______________________________________
3. Was he/she willing to continue his/her participation in SBIRT services?
Yes
No
[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT FOLLOW-UP.]
Was the client able to be contacted for follow-up?
Yes
No
2. What is the follow-up status of the client? [THIS IS A REQUIRED FIELD: NA, REFUSED, DON’T KNOW, AND MISSING WILL NOT BE ACCEPTED.]
01
= Deceased at time of due date
11
= Completed interview within specified window
12
= Completed interview outside specified window
21
= Located, but refused, unspecified
22
= Located, but unable to gain institutional access
23
= Located, but otherwise unable to gain access
24
= Located, but withdrawn from project
31
= Unable to locate, moved
32
= Unable to locate, other (Specify) ________________________
3. Is the client still receiving services from your program?
Yes
No
Please complete Sections B, C, D, E, F, G and those sections of Section H assigned to your program.
[IF THIS IS A FOLLOW-UP INTERVIEW, STOP NOW; THE INTERVIEW IS COMPLETE.]
[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE.]
On what date was the client discharged?
|____|____| / |____|____| / |____|____|____|____|
Month Day Year
What is the client’s discharge status?
01
= Completion/Graduate
02
= Termination
If the client was terminated, what was the reason for termination? [Select one response.]
01
= Left on own against staff advice with satisfactory progress
02
= Left on own against staff advice without satisfactory progress
03
= Involuntarily discharged due to nonparticipation
04
= Involuntarily discharged due to violation of rules
05
= Referred to another program or other services with satisfactory
progress
06
= Referred to another program or other services with unsatisfactory
progress
07
= Incarcerated due to offense committed while in treatment/recovery
with satisfactory progress
08
= Incarcerated due to offense committed while in treatment/recovery
with unsatisfactory progress
09
= Incarcerated due to old warrant or charged from before entering
treatment/recovery with satisfactory progress
10
= Incarcerated due to old warrant or charged from before entering
treatment/recovery with unsatisfactory progress
11
= Transferred to another facility for health reasons
12
= Death
13
= Other (Specify)
Did the program order an HIV test for this this client?
Yes [SKIP
TO QUESTION 5.]
No [GO
TO J4.]
[IF NO] Did the program refer this client for HIV testing with another provider?
Yes
No
Did the program provide Naloxone and/or Fentanyl Test Strips to this client at any time during their involvement in grant funded services?
Naloxone
Fentanyl
Test Strips
Both
Naloxone and Fentanyl Test Strips
Neither
Is the client fully vaccinated against the virus that causes COVID-19?
Yes
No,
partially vaccinated with plans to receive the subsequent vaccination
on time
No,
partially vaccinated with no plan to receive the subsequent
vaccination
No,
client refused vaccination
Refused
to answer
Identify the number of DAYS of services provided to the client during the client’s course of treatment/recovery. [ENTER ZERO IF NO SERVICES PROVIDED.]
Modality Days
1. Case Management |___|___|___|
2. Intensive Outpatient Treatment |___|___|___|
3. Inpatient/Hospital (Other Than Withdrawal Management) |___|___|___|
4. Outpatient Therapy |___|___|___|
5. Outreach |___|___|___|
6. Medication
A. Methadone |___|___|___|
B. Buprenorphine |___|___|___|
C. Naltrexone – Short Acting |___|___|___|
D. Naltrexone – Long Acting (Report
28 days for each one injection) |___|___|___|
E. Disulfiram |___|___|___|
F. Acamprosate |___|___|___|
G. Nicotine Replacement |___|___|___|
H. Bupropion |___|___|___|
I. Varenicline |___|___|___|
7. Residential/Rehabilitation |___|___|___|
8. Withdrawal Management (Select Only 1):
A. Hospital Inpatient |___|___|___|
B. Free Standing Residential |___|___|___|
C. Ambulatory Detoxification |___|___|___|
9. After Care |___|___|___|
10. Recovery Support |___|___|___|
11. Other (Specify) |___|___|___|
Identify the number of SESSIONS provided to the client during the client’s course of treatment/recovery. [ENTER ZERO IF NO SERVICES PROVIDED.]
Treatment Services Sessions
[SBIRT GRANTS: You must have at least one session for one of the Treatment Services numbered 1 through 4.]
1. Screening |___|___|___|
2. Brief Intervention |___|___|___|
3. Brief Treatment |___|___|___|
4. Referral to Treatment |___|___|___|
5. Assessment |___|___|___|
6. Treatment Planning |___|___|___|
7. Recovery Planning |___|___|___|
8. Individual Counseling |___|___|___|
9. Group Counseling |___|___|___|
10. Contingency Management |___|___|___|
11. Community Reinforcement |___|___|___|
12. Cognitive Behavioral Therapy |___|___|___|
13. Family/Marriage Counseling |___|___|___|
14. Co-Occurring Treatment Services |___|___|___|
15. Pharmacological Interventions |___|___|___|
16. HIV/AIDS Counseling |___|___|___|
17. Cultural Interventions/Activities |___|___|___|
18. Other Clinical Services
(Specify) |___|___|___|
Case Management Services Sessions
1. Family Services (E.g Marriage Education, Parenting, Child Development Services) |___|___|___|
2. Child Care |___|___|___|
3. Employment Service
A. Pre-Employment |___|___|___|
B. Employment Coaching |___|___|___|
4. Individual Services Coordination |___|___|___|
5. Transportation |___|___|___|
6. HIV/AIDS Services & Counseling |___|___|___|
7. Transitional Drug-Free Housing Services |___|___|___|
8. Housing Support |___|___|___|
9. Health Insurance Enrollment |___|___|___|
10. Other Case Management Services (Specify) |___|___|___|
Medical Services Sessions
1. Medical Care |___|___|___|
2. Alcohol/Drug Testing |___|___|___|
3. OB/GYN Services |___|___|___|
4. HIV/ AIDS Medical Support & Testing |___|___|___|
5. Hepatitis Medical Support & Testing |___|___|___|
6. Other STI Support and Testing |___|___|___|
7. Dental Care |___|___|___|
8. Other Medical Services
(Specify) |___|___|___|
After Care Services Sessions
1. Continuing Care |___|___|___|
2. Relapse Prevention |___|___|___|
3. Recovery Coaching |___|___|___|
4. Mutual Support Groups |___|___|___|
5. Spiritual Support |___|___|___|
6. Other After Care Services
(Specify) |___|___|___|
Education Services Sessions
1. Substance Misuse Education |___|___|___|
2. HIV/AIDS Education |___|___|___|
3. Hepatitis Education |___|___|___|
4. Other STI Education Services |___|___|___|
5. Naloxone Training |___|___|___|
6. Fentanyl Test Strip Training |___|___|___|
7. Other Education
Services
(Specify) |___|___|___|
Recovery Support Services Sessions
1. Peer Coaching or Mentoring |___|___|___|
2. Vocational Services |___|___|___|
3. Recovery Housing |___|___|___|
4. Recovery Planning |___|___|___|
5. Case Management Services to Specifically Support Recovery |___|___|___|
6. Alcohol- and Drug-Free Social Activities |___|___|___|
7. Information and Referral |___|___|___|
8. Other Recovery Support Services (Specify) _________________________ |___|___|___|
9. Other Peer-to-Peer Recovery Support Services (Specify) |___|___|___|
Has this client attended 60% or more of their planned services?
Yes
No
Did this client receive any services via telehealth or a virtual platform?
Yes
No
Has this client previously been diagnosed with an opioid use disorder?
Yes
No [SKIP TO 5]
a. [IF YES] In the past 30 days, which FDA-approved medication did the client receive for the treatment of this opioid use disorder? [CHECK ALL THAT APPLY.]
Methadone
[IF RECEIVED] Specify how many days received
|___|___|
Buprenorphine
[IF RECEIVED] Specify how many days received
|___|___|
Naltrexone
[IF RECEIVED] Specify how many days received
|___|___|
Extended‒release Naltrexone
[IF RECEIVED] Specify how many doses received
|___|___|
Client did not receive an FDA-approved medication for an opioid
use disorder
[IF YES] Has this client taken the medication as prescribed?
Yes
No
Has this client previously been diagnosed with an alcohol use disorder?
Yes
No [SKIP TO 6]
a. [IF YES] In the past 30 days, which FDA-approved medication did the client receive for the treatment of this alcohol use disorder? [CHECK ALL THAT APPLY.]
Naltrexone
[IF RECEIVED] Specify how many days received
|___|___|
Extended‒release Naltrexone [IF
RECEIVED] Specify how many doses received |___|___|
Disulfiram
[IF RECEIVED] Specify how many days received
|___|___|
Acamprosate
[IF RECEIVED] Specify how many days received
|___|___|
Client did not receive an FDA-approved medication for an alcohol
use disorder
[IF YES] Has this client taken the medication as prescribed?
Yes
No
Has this client previously been diagnosed with a stimulant use disorder?
Yes
No [SKIP TO 7]
a. [IF YES] In the past 30 days, which evidence-based interventions did the client receive for the treatment of this stimulant use disorder? [CHECK ALL THAT APPLY.]
Contingency Management [IF
RECEIVED] Specify how many days received |___|___|
Community Reinforcement [IF
RECEIVED] Specify how many days received |___|___|
Cognitive Behavioral Therapy [IF
RECEIVED] Specify how many days received |___|___|
Other Treatment Approach [IF
RECEIVED] Specify how many days received |___|___|
Client did not receive any intervention
[IF YES] Has this client attended and participated in evidence-based interventions for stimulant use disorder?
Yes
No
Has this client previously been diagnosed with a tobacco use disorder?
Yes
No [SKIP TO REMAINING DISCHARGE QUESTIONS.]
a. [IF YES] In the past 30 days, which FDA-approved medication did the client receive for the treatment of this tobacco use disorder? [CHECK ALL THAT APPLY.]
Nicotine Replacement [IF
RECEIVED] Specify how many days received |___|___|
Bupropion
[IF RECEIVED] Specify how many days received
|___|___|
Varenicline
[IF RECEIVED] Specify how many days received
|___|___|
Client did not receive an FDA-approved medication for a tobacco
use disorder
[IF YES] Has this client taken the medication as prescribed?
Yes
No
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Subject | Government Performance and Results Act (GPRA) - Client Outcome Measures for Discretionary Programs |
Author | Center for Substance Abuse Treatment (CSAT) |
File Modified | 0000-00-00 |
File Created | 2022-03-08 |