Form CSAT GPRA Tool CSAT GPRA Tool CSAT GPRA Tool

Government Performance and Results Act Client/Participant Outcome Measures

CSAT GPRA Tool Re-Draft CLEAN_12-03-2021

GPRA Client Outcome

OMB: 0930-0208

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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.







A. Record Management

Client ID |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|

Client Description by Grant Type:

Shape1 Treatment grant client

Shape2 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? Shape3 Yes Shape4 No
[IF NO, GO DIRECTLY TO SECTION I.]

6-month follow-up  → → → Did you conduct a follow-up interview? Shape5 Yes Shape6 No
[IF NO, GO DIRECTLY TO SECTION I.]

Discharge → → → Did you conduct a discharge interview? Shape7 Yes Shape8 No
[IF NO, GO DIRECTLY TO SECTION J.]

Interview Date |____|____| / |____|____| / |____|____|____|____|
 Month Day Year




















A. Record Management - Demographics [Asked only at intake/baseline.]

  1. What is your birth month and year?

|____|____| / |____|____|____|____|
Month Year

Shape9 Refused

  1. What do you consider yourself to be??

Shape10 Male

Shape11 Female

Shape12 Transgender (Male to Female)

Shape13 Transgender (Female to Male)

Shape14 Gender non-conforming

Shape15 Other (Specify)______________________________

Shape16 Refused

  1. Are you Hispanic, Latino/a, or Spanish origin?

Shape17 Yes

Shape18 No [SKIP TO QUESTION 4]

Shape19 Refused [SKIP TO QUESTION 4]

[IF YES] What ethnic group do you consider yourself? You may indicate more than one.

Shape20 Central American

Shape21 Cuban

Shape22 Dominican

Shape23 Mexican

Shape24 Puerto Rican

Shape25 South American

Shape26 Other (Specify)_____________

Shape27 Refused

  1. What is your race? You may indicate more than one.

Shape28 Black or African American

Shape29 White

Shape30 American Indian

Shape31 Alaska Native

Shape32 Asian Indian

Shape33 Chinese

Shape34 Filipino

Shape35 Japanese

Shape36 Korean

Shape37 Vietnamese

Shape38 Other Asian

Shape39 Native Hawaiian

Shape40 Guamanian or Chamorro

Shape41 Samoan

Shape42 Other Pacific Islander

Shape43 Other (Specify)_____________

Shape44 Refused

  1. Do you speak a language other than English at home?

  • Yes

  • No


IF YES, what is this language?


  • Spanish

  • Other ___________

  1. Do you think of yourself as…

Shape45 Straight Or Heterosexual

Shape46 Homosexual (Gay Or Lesbian)

Shape47 Bisexual

Shape48 Queer, Pansexual, And/Or Questioning

Shape49 Asexual

Shape50 Something Else? Please Specify ___________________________________

Shape51 Refused

  1. What is your relationship status?

Shape52 Married

Shape53 Single

Shape54 Divorced

Shape55 Separated

Shape56 Widowed

Shape57 In a relationship

Shape58 In multiple relationships

Shape59 Refused

  1. [IF NOT MALE] Are you currently pregnant?

Shape60 Yes

Shape61 No

Shape62 Do not know

Shape63 Refused

  1. Do you have children? [Refers to children both living and/or who may have died]

Shape64 Yes

Shape65 No [SKIP TO QUESTION 10]

Shape66 Refused [SKIP TO QUESTION 10]

a. How many children under the age of 18 do you have?

|____|____| Shape67  Refused

b. Are any of your children, who are under the age of 18, living with someone else due to a court’s intervention?

Shape68 Yes Number of children removed from client’s care |____|____|

Shape69 No [SKIP TO QUESTION 10]

Shape70 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.]

Shape71 Yes Number of children with whom the client has been reunited |____|____|

Shape72 No

Shape73 Refused

  1. 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?

Shape74 No

Shape75 Yes, In The Armed Forces

Shape76 Yes, In The Reserves

Shape77 Yes, In The National Guard

Shape78 Yes, Other Uniformed Services [Includes NOAA, USPHS]

Shape79 Refused

11. How long does it take you, on average, to travel to the location where you receive services provided by this grant?

Shape80 Half an hour or less

Shape81 Between half an hour and one hour

Shape82 Between one hour and one and a half hours

Shape83 Between one and a half hours and two hours

Shape84 Two hours or more

Shape85 Refused


b. SUBSTANCE uSE AND PLANNED SERVICES

1. Using the table below, please indicate the following:



  1. 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.


  1. 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.

Other

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)

|___|___|

|___|






  1. 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.]

Shape86 Naltrexone [IF RECEIVED] Specify how many days received |___|___|

Shape87 Extended‒release Naltrexone [IF RECEIVED] Specify how many doses received |___|___|

Shape88 Disulfiram [IF RECEIVED] Specify how many days received |___|___|

Shape89 Acamprosate [IF RECEIVED] Specify how many days received |___|___|

Shape90 Did not receive an FDA-approved medication for a diagnosed alcohol use disorder

Shape91 Client does not report such a diagnosis



  1. 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.]

Shape92 Methadone [IF RECEIVED] Specify how many days received |___|___|

Shape93 Buprenorphine [IF RECEIVED] Specify how many days received |___|___|

Shape94 Naltrexone [IF RECEIVED] Specify how many days received |___|___|

Shape95 Extended‒release Naltrexone [IF RECEIVED] Specify how many doses received |___|___|

Shape96 Did not receive an FDA-approved medication for a diagnosed opioid use disorder

Shape97 Client does not report such a diagnosis



  1. 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?

Shape98 Contingency Management [IF RECEIVED] Specify how many days received |___|___|

Shape99 Community Reinforcement [IF RECEIVED] Specify how many days received |___|___|

Shape100 Cognitive Behavioral Therapy [IF RECEIVED] Specify how many days received |___|___|

Shape101 Other evidence-based intervention [IF RECEIVED] Specify how many days received |___|___|

Shape102 Did not receive any intervention for a diagnosed stimulant use disorder

Shape103 Client does not report such a diagnosis


  1. 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.]

Shape104 Nicotine Replacement [IF RECEIVED] Specify how many days received |___|___|

Shape105 Bupropion [IF RECEIVED] Specify how many days received |___|___|

Shape106 Varenicline [IF RECEIVED] Specify how many days received |___|___|

Shape107 Did not receive an FDA-approved medication for a diagnosed tobacco use disorder

Shape108 Client does not report such a diagnosis


  1. 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?

Shape109 Yes [IF YES, SPECIFY BELOW, IN QUESTION 7]

Shape110 No [IF NO, MOVE TO QUESTION 8]

Shape111 Refused [MOVE TO QUESTION 8]



  1. 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.

Shape112 Naloxone (Narcan)

Shape113 Care in an Emergency Department

Shape114 Care from a Primary Care Provider

Shape115 Admission to a hospital

Shape116 Supervision by someone else

Shape117 Other (Specify) ______________________________

Shape118 Refused


  1. 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?

Shape119 One time

Shape120 Two times

Shape121 Three times

Shape122 Four times

Shape123 Five times

Shape124 Six or more times

Shape125 Never [SKIP TO QUESTION 10]

Shape126 Refused [SKIP TO QUESTION 10]



  1. Approximately when was the last time you received inpatient or outpatient treatment for a substance use disorder?

Shape127 Less than 6 months ago

Shape128 Between 6 months and one year ago

Shape129 One to two years ago

Shape130 Two to three years ago

Shape131 Three to four years ago

Shape132 Five or more years ago

Shape133 Refused



  1. Have you ever been diagnosed with a mental health illness by a health care professional?

Shape134 Yes

Shape135 No [SKIP TO QUESTION 11]

Shape136 Refused [SKIP TO QUESTION 11]




  1. [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

[FOLLOW-UP AND DISCHARGE INTERVIEWS: SKIP TO SECTION C. AT INTAKE, CONTINUE WITH THE FOLLOWING QUESTIONS]

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?

Shape137 Yes

Shape138 No [SKIP TO QUESTION 12]

11a. [IF YES] Did the client screen positive for co-occurring mental health and substance use
disorders?

Shape139 Yes

Shape140 No


11b. [IF YES] Was the client referred for further assessment for a co-occurring mental health and

substance use disorder?


Shape141 Yes

Shape142 No

b 12. Planned Services PROVIDED UNDER GRANT FUNDING [Reported by program staff about client only at intake/baseline.]

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 Shape143

2. Intensive Outpatient Treatment Shape144

3. Inpatient/Hospital (Other Than Withdrawal Management) Shape145

4. Outpatient Therapy Shape146

5. Outreach Shape147

6. Medication

A. Methadone Shape148

B. Buprenorphine Shape149

C. Naltrexone – Short Acting Shape150

D. Naltrexone – Long Acting Shape151

E. Disulfiram Shape152

F. Acamprosate Shape153

G. Nicotine Replacement Shape154

H. Bupropion Shape155

I. Varenicline Shape156

7. Residential/Rehabilitation Shape157

8. Withdrawal Management (Select Only One)

A. Hospital Inpatient Shape158

B. Free Standing Residential Shape159

C. Ambulatory Detoxification Shape160

9. After Care Shape161

10. Recovery Support Shape162

11. Other (Specify) Shape163

[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 Shape164

2. Brief Intervention Shape165

3. Brief Treatment Shape166

4. Referral to Treatment Shape167

5. Assessment Shape168

6. Treatment Planning Shape169

7. Recovery Planning Shape170

8. Individual Counseling Shape171

9. Group Counseling Shape172

10. Contingency Management Shape173

11. Community Reinforcement Shape174

12. Cognitive Behavioral Therapy Shape175

13. Family/Marriage Counseling Shape176

14. Co-Occurring Treatment Services Shape177

15. Pharmacological Interventions Shape178

16. HIV/AIDS Counseling Shape179

17. Cultural Interventions/Activities Shape180

18. Other Clinical Services
(Specify) Shape181

Case Management Services

1. Family Services (E.g. Marriage Education, Parenting, Child Development Services) Shape182

2. Child Care Shape183

3. Employment Service

A. Pre-Employment Shape184

B. Employment Coaching Shape185

4. Individual Services Coordination Shape186

5. Transportation Shape187

6. HIV/AIDS Services

A. If HIV Neg, Pre-Exposure Prophylaxis Shape188

B. If HIV Neg, Post-Exposure Prophylaxis Shape189

C. If HIV Positive, HIV Treatment Shape190

7. Transitional Drug-Free Housing Services Shape191

8. Housing Support Shape192

9. Health Insurance Enrollment Shape193

10. Other Case Management Services
(Specify) Shape194

Medical Services

1. Medical Care Shape195

2. Alcohol/Drug Testing Shape196

3. OB/GYN Services Shape197

4. HIV/AIDS Medical Support & Testing Shape198

5. Dental Care Shape199

6. Viral Hepatitis Medical Support & Testing Shape200

7. Other STI Support & Testing Shape201

8. Other Medical Services
(Specify) Shape202

After Care Services

1. Continuing Care Shape203

2. Relapse Prevention Shape204

3. Recovery Coaching Shape205

4. Self-Help and Mutual Support Groups Shape206

5. Spiritual Support Shape207

6. Other After Care Services
(Specify) Shape208

Education Services

1. Substance Use Education Shape209

2. HIV/AIDS Education Shape210

3. Naloxone Training Shape211

4. Fentanyl Test Strip Training Shape212

5. Viral Hepatitis Education Shape213

6. Other STI Education Services Shape214

7. Other Education Services
(Specify) Shape215

Recovery Support Services

1. Peer Coaching or Mentoring Shape216

2. Vocational Services Shape217

3. Recovery Housing Shape218

4. Recovery Planning Shape219

5. Case Management Services to Specifically Support Recovery Shape220

6. Alcohol- and Drug-Free Social Activities Shape221

7. Information and Referral Shape222

8. Other Recovery Support Services (Specify)_________________________ Shape223

9. Other Peer-to-Peer Recovery Support Services (Specify) Shape224

C. Living Conditions

  1. In the past 30 days, where have you been living most of the time? [DO NOT READ RESPONSE OPTIONS TO CLIENT.]

Shape225 Shelter (Safe Havens, Transitional Living Center [TLC], Low-Demand Facilities, Reception Centers, Other Temporary Day or Evening Facility)

Shape226 Street/Outdoors (Sidewalk, Doorway, Park, Public Or Abandoned Building)

Shape227 Institution (Hospital, Nursing Home, Jail/Prison)

Shape228 Housed: [IF HOUSED, CHECK APPROPRIATE SUBCATEGORY:]

Shape229 Own/Rental Apartment, Room, Trailer, Or House

Shape230 Someone Else’s Apartment, Room, Trailer, Or House (including couch surfing)

Shape231 Dormitory/College Residence

Shape232 Halfway House or Transitional Housing

Shape233 Residential Treatment

Shape234 Recovery Residence/Sober Living

Shape235 Other Housed (Specify)

Shape236 Refused

  1. Do you currently live with any person who, over the past 30 days, has regularly used alcohol or other substances?

Shape237 Yes

Shape238 No

Shape239 No, lives alone

Shape240 Refused



D. Education, Employment, and Income

  1. 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.”]

Shape241 Not Enrolled

Shape242 Enrolled, Full Time

Shape243 Enrolled, Part Time


Shape244 Refused

  1. What is the highest level of education you have finished, whether or not you received a degree?

Shape245 Less than 12th Grade

Shape246 12th Grade/High School Diploma/Equivalent

Shape247 Vocational/Technical (Voc/Tech) Diploma

Shape248 Some College or University

Shape249 Bachelor’s Degree (For example: BA, BS)

Shape250 Graduate Work/Graduate Degree

Shape251 Other (Specify)____________________________________

Shape252 Refused

Don’t Know

  1. 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.”]

Shape253 Employed, Full Time (35+ Hours Per Week, Or Would Be, If Not For Leave or An Excused Absence)

Shape254 Employed, Part Time

Shape255 Unemployed—But Looking For Work

Shape256 Not Employed, NOT Looking For Work

Shape257 Not working due to a disability

Shape258 Retired, not working

Shape259 Other (Specify)

Shape260 Refused




4. Do you, individually, have enough money to pay for the following living expenses? Choose all that apply.



Shape261 Food

Shape262 Clothing

Shape263 Transportation

Shape264 Rent/Housing

Shape265 Utilities (Gas/Water/Electric)

Shape266 Telephone Connection (Cell or Landline)

Shape267 Childcare

Shape268 Health Insurance

Shape269 Refused









5. What is your personal annual income, meaning the total pre-tax income from all sources, earned in the past year?

Shape270 $0 to $9,999

Shape271 $10,000 to $14,999

Shape272 $15,000 to $19,999

Shape273 $20,000 to $34,999

Shape274 $35,000 to $49,999

Shape275 $50,000 to $74,999

Shape276 $75,000 to $99,999

Shape277 $100,000 to $199,999

Shape278 $200,000 or more

Shape279 Refused




































E. Legal

  1. 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 Shape280  Refused Shape281  Currently Incarcerated

  1. Are you currently awaiting charges, trial, or sentencing?

Shape282 Yes

Shape283 No

Shape284 Refused

  1. Are you currently on parole or probation or intensive pretrial supervision?

Shape285 Probation

Shape286 Parole

Shape287 Intensive Pretrial Supervision

Shape288 No

Shape289 Refused

  1. Do you currently participate in a drug court program or are you in a deferred prosecution agreement?

Shape290 Drug court program

Shape291 Deferred prosecution agreement

Shape292 No, neither of these

Shape293 Refused




























F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY

1. How would you rate your quality of life over the past 30 days?


Shape294 Very poor

Shape295 Poor

Shape296 Neither poor nor good

Shape297 Good

Shape298 Very good

Shape299 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 |____|____| Shape300

b. Experienced serious anxiety or tension |____|____| Shape301

c. Experienced hallucinations |____|____| Shape302

d. Experienced trouble understanding, concentrating, or remembering |____|____| Shape303

e. Experienced trouble controlling violent behavior |____|____| Shape304

f. Attempted suicide |____|____| Shape305

g. Been prescribed medication for psychological/emotional problem |____|____| Shape306

[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?

Shape307 Not at all

Shape308 Slightly

Shape309 Moderately

Shape310 Considerably

Shape311 Extremely

Shape312 Refused

Shape313 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.


Shape314 Primary Care Provider

Shape315 Urgent Care

Shape316 The Emergency Department

Shape317 A specialist doctor

Shape318 No care was sought

Shape319 Other _____________________________









F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY (continued)

5. Do you currently have medical/health insurance?


Shape320 Yes

Shape321 No [SKIP TO NEXT SECTION]

Shape322 Refused


5a. [IF YES] What type of insurance do you have (Select all that apply)?

Shape323 Medicare

Shape324 Medicaid

Shape325 Private Insurance or Employer Provided

Shape326 TRICARE or other military health care

Shape327 An assistance program [for example, a medication assistance program]

Shape328 Any other type of health insurance or health coverage plan (Specify)______________________

Shape329 Refused
































G. Social Connectedness

  1. 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.

Shape330 Yes [IF YES] Specify How Many Times |____|____| Shape331  Refused

Shape332 No

Shape333 Refused

  1. In the past 30 days, did you have interaction with family and/or friends that are supportive of your recovery?

Shape334 Yes

Shape335 No

Shape336 Refused

  1. How satisfied are you with your personal relationships?

Shape337 Very Dissatisfied

Shape338 Dissatisfied

Shape339 Neither Satisfied nor Dissatisfied

Shape340 Satisfied

Shape341 Very Satisfied

Shape342 Refused

  1. In the past 30 days did you realize that you need to change those social connections or places that negatively impact your recovery?

Shape343 Yes

Shape344 No

Shape345 Refused


YOU ARE NOT RESPONSIBLE FOR COLLECTING DATA ON ALL SECTION H QUESTIONS. YOUR GPO HAS PROVIDED YOU WITH GUIDANCE ON WHICH SPECIFIC SECTION H QUESTIONS YOU ARE TO COMPLETE. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT YOUR GPO.

H1. PROGRAM SPECIFIC QUESTIONS


[QUESTION 1 SHOULD BE REPORTED BY GRANTEE STAFF AT FOLLOW-UP AND DISCHARGE]

  1. Which of the following occurred for the client, subsequent to receiving treatment? [CHECK ALL THAT APPLY]

Shape346 Client was reunited with child (or children)

[IF YES] With Agency Supervision Shape347

[OR] Without Agency Supervision Shape348

Shape349 Client avoided out of home placement for child (or children)

Shape350 None of the above







H2. PROGRAM SPECIFIC QUESTIONS

[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]


  1. Did the [insert grantee name] help you obtain any of the following benefits? [CHECK ALL THAT APPLY]


Shape351 Private Health Insurance

Shape352 Medicaid

Shape353 Medicare

Shape354 SSI/SSDI

Shape355 TANF

Shape356 SNAP

Shape357 Other (Specify)

Shape358 None Of The Above

Shape359 Refused







H3. PROGRAM SPECIFIC QUESTIONS


[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

Shape360 Yes

Shape361 No

Shape362 Refused

Shape363 Yes

Shape364 No

Shape365 Refused

1b. Enrolled in vocational training

Shape366 Yes

Shape367 No

Shape368 Refused

Shape369 Yes

Shape370 No

Shape371 Refused

1c. Currently employed

Shape372 Yes

Shape373 No

Shape374 Refused

Shape375 Yes

Shape376 No

Shape377 Refused

1d. Living in stable housing

Shape378 Yes

Shape379 No

Shape380 Refused

Shape381 Yes

Shape382 No

Shape383 Refused

















H4. PROGRAM SPECIFIC QUESTIONS


[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]


  1. 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.



Shape384 Strongly disagree

Shape385 Disagree

Shape386 Undecided

Shape387 Agree

Shape388 Strongly Agree

Shape389 Refused


  1. As a result of treatment, I feel I now have the skills and support to balance parenting and managing my recovery.

Shape390 Strongly disagree

Shape391 Disagree

Shape392 Undecided

Shape393 Agree

Shape394 Strongly Agree

Shape395 Refused


H5. PROGRAM SPECIFIC QUESTIONS

[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]


  1. Please indicate the degree to which you agree or disagree with the following statements:



  1. 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.



Shape396 Strongly disagree

Shape397 Disagree

Shape398 Undecided

Shape399 Agree

Shape400 Strongly Agree

Shape401 Refused


  1. As a result of treatment, I feel I now have the skills and support to balance parenting and managing my recovery.



Shape402 Strongly disagree

Shape403 Disagree

Shape404 Undecided

Shape405 Agree

Shape406 Strongly Agree

Shape407 Refused


H6. PROGRAM SPECIFIC QUESTIONS

[QUESTION 1 SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOW-UP, AND DISCHARGE].


  1. Please indicate which type of funding was/will be used to pay for the SBIRT services provided to this client. [CHECK ALL THAT APPLY.]


Shape408 Current SAMHSA grant funding

Shape409 Other federal grant funding

Shape410 State funding

Shape411 Client’s private insurance

Shape412 Medicaid/Medicare

Shape413 TRICARE

Shape414 Other (Specify)____________________


[IF FOLLOW-UP OR DISCHARGE INTERVIEW, SKIP TO H3.]



[QUESTION 2 SHOULD BE REPORTED BY GRANTEE STAFF ONLY AT INTAKE/BASELINE]


  1. 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]


  1. Did the client receive the following types of services?

Yes No

Brief Intervention Y N

Brief Treatment Y N

Referral to Treatment Y N











H7. PROGRAM SPECIFIC QUESTIONS

[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?

Shape415 Yes

Shape416 No [SKIP TO QUESTION 2.]

Shape417 Not Permitted To Ask [SKIP TO QUESTION 2.]

Shape418 Refused [SKIP TO QUESTION 2.]

[IF YES] Altogether, in the past 30 days, how many: Response Refused

a. Sexual partners did you have? Number: |____|____|____| Shape419

b. Did you engage in unprotected/condomless sex?

Shape420 Yes

Shape421 No → [SKIP TO QUESTION 2.]

c. [If yes] Were any of your partners:

1. Living with HIV and not taking HIV medications Shape422 Yes Shape423 No Shape424

2. A person who injects drugs Shape425 Yes Shape426 No Shape427

3. High on one or more substances Shape428 Yes Shape429 No Shape430

2. Are you currently taking Pre-Exposure Prophylaxis (PrEP) for HIV prevention, or are you taking medication for the treatment of HIV?

Shape431 PrEP

Shape432 Treatment for HIV

Shape433 Neither

Shape434 Refused


  1. Did the program provide access to the following?


A1. An HIV test?


Shape435 Yes

Shape436 No [SKIP TO 3B.1]

Shape437 Refused [SKIP TO 3B.1]


A2. [IF YES] Was this the first time that you had been tested for HIV?

Shape438 Yes

Shape439 No [SKIP TO QUESTION A5]

Shape440 Refused [SKIP TO QUESTION A5]


A3. [IF YES] Was HIV testing performed on-site or were you referred out for testing?

Shape441 On-site [SKIP TO QUESTION A5]

Shape442 Referred out

Shape443 Refused [SKIP TO QUESTION A5]




A4. [IF REFFERED OUT FOR TESTING] Where was testing performed?

Shape444 Primary Care Provider’s office

Shape445 Dedicated clinic

Shape446 VA Medical Center

Shape447 Health Center or Community Clinic

Shape448 Local Health Department

Shape449 Specialty Addiction Treatment Program

Shape450 Sexual Health Center

Shape451 A mobile testing service

Shape452 Other _________________


A5. What was the result?

Shape453 Positive

Shape454 Negative [SKIP TO A12]

Shape455 Indeterminate

Shape456 Refused [SKIP TO 3B.1]


A6. [IF POSITIVE OR INDETERMINATE] Did you receive confirmatory testing?

Shape457 Yes

Shape458 No [SKIP TO QUESTION A8]

Shape459 Refused [SKIP TO QUESTION A8]


A7. [IF YES] What was the result?

Shape460 Positive

Shape461 Negative

Shape462 Indeterminate

Shape463 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?

Shape464 Primary Care Provider’s office

Shape465 Dedicated clinic

Shape466 VA Medical Center

Shape467 Health Center or Community Clinic

Shape468 Local Health Department

Shape469 Specialty Addiction Treatment Program

Shape470 Sexual Health Center

Shape471 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?

Shape472 1

Shape473 2

Shape474 3

Shape475 4 or more

Shape476 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)

Shape477 PrEP

Shape478 PEP

Shape479 Received Counseling

Shape480 Did not receive medications

Shape481 Did not receive counseling

Shape482 Refused


B1. Did you receive a Rapid Hepatitis C (HCV) test


Shape483 Yes

Shape484 No [SKIP TO 3C.1]

Shape485 Refused [SKIP TO 3C.1]


B2. [IF YES] Was this followed up with confirmatory Hepatitis C (HCV RNA) testing?

Shape486 Yes

Shape487 No [SKIP TO QUESTION B4]


B3. [IF YES] What was the result?

Shape488 Positive

Shape489 Negative [SKIP TO 3C.1]

Shape490 Indeterminate

Shape491 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?


Shape492 Yes

Shape493 No [SKIP TO 3D.1]

Shape494 Refused [SKIP TO 3D.1]

C2. [IF YES] What was the result?

Shape495 Positive

Shape496 Negative [SKIP TO 3D.1]

Shape497 Indeterminate

Shape498 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?


Shape499 Yes [SKIP TO SECTION I OR J/K]

Shape500 No

Shape501 Refused [SKIP TO SECTION I OR J/K]

D2. [IF NO] Was the client referred out for vaccination?

Shape502 Yes

Shape503 No

Shape504 Refused


H8. PROGRAM SPECIFIC QUESTIONS [QUESTIONS 1 AND 2 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]


1. Is peer support available at this program?


Shape505 Yes [COMPLETE QUESTIONS 2 AND 3]

Shape506 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

Shape507 Yes

Shape508 No

Shape509 Refused

Shape510 Yes

Shape511 No

Shape512 Refused

1b. Enrolled in vocational training

Shape513 Yes

Shape514 No

Shape515 Refused

Shape516 Yes

Shape517 No

Shape518 Refused

1c. Currently employed

Shape519 Yes

Shape520 No

Shape521 Refused

Shape522 Yes

Shape523 No

Shape524 Refused

1d. Living in stable housing

Shape525 Yes

Shape526 No

Shape527 Refused

Shape528 Yes

Shape529 No

Shape530 Refused


  1. To what extent has this program improved your quality of life?



Shape531 To a great extent

Shape532 Somewhat

Shape533 Very little

Shape534 Not at all

Shape535 Refused











H9. PROGRAM SPECIFIC QUESTIONS

[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]



  1. 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.



Shape536 Strongly disagree

Shape537 Disagree

Shape538 Undecided

Shape539 Agree

Shape540 Strongly Agree

Shape541 Not Applicable

Shape542 Refused


ii. The use of technology accessed through [insert grantee name] has helped me reduce my substance use.



Shape543 Strongly disagree

Shape544 Disagree

Shape545 Undecided

Shape546 Agree

Shape547 Strongly Agree

Shape548 Not Applicable

Shape549 Refused


iii. The use of technology accessed through [insert grantee name] has helped me manage my mental health symptoms.



Shape550 Strongly disagree

Shape551 Disagree

Shape552 Undecided

Shape553 Agree

Shape554 Strongly Agree

Shape555 Not Applicable

Shape556 Refused


iv. The use of technology accessed through [insert grantee name] has helped me support my recovery.



Shape557 Strongly disagree

Shape558 Disagree

Shape559 Undecided

Shape560 Agree

Shape561 Strongly Agree

Shape562 Not Applicable

Shape563 Refused

H10. PROGRAM SPECIFIC QUESTIONS

[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]


  1. Did the client screen positive for, or have a history of, a mental health disorder?


Shape564 Client screened positive

Shape565 Client screened negative [SKIP TO QUESTION 2.]

Shape566 Client was not screened [SKIP TO QUESTION 2.]

Shape567 Client has a positive history


a. [IF POSITIVE] Was the client referred to mental health services?


Shape568 Yes

Shape569 No [SKIP TO H2.]


b. [IF YES] Did the client receive mental health services?


Shape570 Yes

Shape571 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]


  1. Did the client screen positive for, or have a history of, substance use disorder(s)?


Shape572 Client screened positive

Shape573 Client screened negative

Shape574 Client was not screened

Shape575 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?


Shape576 Yes

Shape577 No


b. [IF YES] Did the client receive substance use disorder services?


Shape578 Yes

Shape579 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]


H10. PROGRAM SPECIFIC QUESTIONS (continued)


[QUESTION 3 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]


  1. 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.



Shape580 Strongly disagree

Shape581 Disagree

Shape582 Undecided

Shape583 Agree

Shape584 Strongly Agree

Shape585 Refused







H11. PROGRAM SPECIFIC QUESTIONS (continued)


THIS SECTION FOR SBIRT GRANTS ONLY [ITEMS TO BE REPORTED AT INTAKE/BASELINE].


1. When the SBIRT was administered, how did the client screen?

Shape586 Negative

Shape587 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?

Shape588 Yes

Shape589 No























I. Follow-Up Status

[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT FOLLOW-UP.]

  1. Was the client able to be contacted for follow-up?

Shape590 Yes

Shape591 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.]

Shape592 01 = Deceased at time of due date

Shape593 11 = Completed interview within specified window

Shape594 12 = Completed interview outside specified window

Shape595 21 = Located, but refused, unspecified

Shape596 22 = Located, but unable to gain institutional access

Shape597 23 = Located, but otherwise unable to gain access

Shape598 24 = Located, but withdrawn from project

Shape599 31 = Unable to locate, moved

Shape600 32 = Unable to locate, other (Specify) ________________________


3. Is the client still receiving services from your program?

Shape601 Yes

Shape602 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.]

J. Discharge Status

[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE.]

  1. On what date was the client discharged?

|____|____| / |____|____| / |____|____|____|____|
Month Day Year

  1. What is the client’s discharge status?

Shape603 01 = Completion/Graduate

Shape604 02 = Termination

If the client was terminated, what was the reason for termination? [Select one response.]

Shape605 01 = Left on own against staff advice with satisfactory progress

Shape606 02 = Left on own against staff advice without satisfactory progress

Shape607 03 = Involuntarily discharged due to nonparticipation

Shape608 04 = Involuntarily discharged due to violation of rules

Shape609 05 = Referred to another program or other services with satisfactory progress

Shape610 06 = Referred to another program or other services with unsatisfactory progress

Shape611 07 = Incarcerated due to offense committed while in treatment/recovery with satisfactory progress

Shape612 08 = Incarcerated due to offense committed while in treatment/recovery with unsatisfactory progress

Shape613 09 = Incarcerated due to old warrant or charged from before entering treatment/recovery with satisfactory progress

Shape614 10 = Incarcerated due to old warrant or charged from before entering treatment/recovery with unsatisfactory progress

Shape615 11 = Transferred to another facility for health reasons

Shape616 12 = Death

Shape617 13 = Other (Specify)

  1. Did the program order an HIV test for this this client?

Shape618 Yes [SKIP TO QUESTION 5.]

Shape619 No [GO TO J4.]

  1. [IF NO] Did the program refer this client for HIV testing with another provider?

Shape620 Yes

Shape621 No

  1. Did the program provide Naloxone and/or Fentanyl Test Strips to this client at any time during their involvement in grant funded services?

Shape622 Naloxone

Shape623 Fentanyl Test Strips

Shape624 Both Naloxone and Fentanyl Test Strips

Shape625 Neither

  1. Is the client fully vaccinated against the virus that causes COVID-19?

Shape626 Yes

Shape627 No, partially vaccinated with plans to receive the subsequent vaccination on time

Shape628 No, partially vaccinated with no plan to receive the subsequent vaccination

Shape629 No, client refused vaccination

Shape630 Refused to answer

K.1 Services Received UNDER GRANT fUNDING [REPORTED BY PROGRAM STAFF ONLY AT DISCHARGE]


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) |___|___|___|

  1. Has this client attended 60% or more of their planned services?

Shape631 Yes

Shape632 No

  1. Did this client receive any services via telehealth or a virtual platform?

Shape633 Yes

Shape634 No

  1. Has this client previously been diagnosed with an opioid use disorder?

Shape635 Yes

Shape636 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.]


Shape637 Methadone [IF RECEIVED] Specify how many days received |___|___|

Shape638 Buprenorphine [IF RECEIVED] Specify how many days received |___|___|

Shape639 Naltrexone [IF RECEIVED] Specify how many days received |___|___|

Shape640 Extended‒release Naltrexone [IF RECEIVED] Specify how many doses received |___|___|

Shape641 Client did not receive an FDA-approved medication for an opioid use disorder

    1. [IF YES] Has this client taken the medication as prescribed?

Shape642 Yes

Shape643 No

  1. Has this client previously been diagnosed with an alcohol use disorder?

Shape644 Yes

Shape645 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.]


Shape646 Naltrexone [IF RECEIVED] Specify how many days received |___|___|

Shape647 Extended‒release Naltrexone [IF RECEIVED] Specify how many doses received |___|___|

Shape648 Disulfiram [IF RECEIVED] Specify how many days received |___|___|

Shape649 Acamprosate [IF RECEIVED] Specify how many days received |___|___|

Shape650 Client did not receive an FDA-approved medication for an alcohol use disorder

    1. [IF YES] Has this client taken the medication as prescribed?

Shape651 Yes

Shape652 No

  1. Has this client previously been diagnosed with a stimulant use disorder?

Shape653 Yes

Shape654 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.]


Shape655 Contingency Management [IF RECEIVED] Specify how many days received |___|___|

Shape656 Community Reinforcement [IF RECEIVED] Specify how many days received |___|___|

Shape657 Cognitive Behavioral Therapy [IF RECEIVED] Specify how many days received |___|___|

Shape658 Other Treatment Approach [IF RECEIVED] Specify how many days received |___|___|

Shape659 Client did not receive any intervention

    1. [IF YES] Has this client attended and participated in evidence-based interventions for stimulant use disorder?

Shape660 Yes

Shape661 No

  1. Has this client previously been diagnosed with a tobacco use disorder?

Shape662 Yes

Shape663 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.]

Shape664 Nicotine Replacement [IF RECEIVED] Specify how many days received |___|___|

Shape665 Bupropion [IF RECEIVED] Specify how many days received |___|___|

Shape666 Varenicline [IF RECEIVED] Specify how many days received |___|___|

Shape667 Client did not receive an FDA-approved medication for a tobacco use disorder

    1. [IF YES] Has this client taken the medication as prescribed?

Shape668 Yes

Shape669 No



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
SubjectGovernment Performance and Results Act (GPRA) - Client Outcome Measures for Discretionary Programs
AuthorCenter for Substance Abuse Treatment (CSAT)
File Modified0000-00-00
File Created2022-08-17
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