CMHS NOMs Tool_816-2022_ Clean

CMHS NOMs Client Level Measures Data Collection Tool_Clean.docx

Mental Health Client/Consumer Outcome Measures and Infrastructure, Prevention and Promotion Indicators

CMHS NOMs Tool_816-2022_ Clean

OMB: 0930-0285

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Form Approved

OMB No. 0930-0285

Expiration Date 03/30/2025

Substance Abuse and Mental Health Services Administration (SAMHSA)

Center for Mental Health Services (CMHS)

National Outcome Measures (NOMs) Client-Level Measures for Discretionary Programs Providing Direct Services

SERVICES TOOL

SAMHSA’s Performance Accountability and Reporting System (SPARS)

August 2022

Public reporting burden for this collection of information is estimated to average 20 minutes per response if all items are asked of a client/consumer/participant; to the extent that providers already obtain much of this information as part of their ongoing client/consumer/participant intake or follow-up, less time will be required. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 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 Office of Management and Budget (OMB) control number. The control number for this project is 0930-0285.




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Table of Contents









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RECORD MANAGEMENT

RECORD MANAGEMENT information is collected by grantee staff at BASELINE, REASSESSMENT, and DISCHARGE, even when an assessment interview is not conducted.

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

Grant ID |____|____|____|____|____|____|____|____|____|____|____|

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

  1. Indicate Assessment Type:

  • Baseline Assessment

  • Reassessment
    (3-month or 6-month)

  • Clinical Discharge Assessment

1a. [IF QUESTION 1 IS BASELINE] Enter the MONTH and YEAR when the client first received services under this grant for this episode of care.



 

|____|____| / |____|____|____|____|
MONTH YEAR


 

2. What is the client’s month and year of birth?

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

MONTH YEAR

3. Was the assessment interview conducted?

  • Yes

  • No

3a. [IF QUESTION 3 IS YES] When?

|____|____| / |____|____| /|____|____|____|____|
MONTH DAY YEAR

3b. [IF QUESTION 3 IS NO] Why not? Choose only one.

  • Not able to obtain consent from proxy

  • Client was impaired or unable to provide consent

  • Client refused this interview

  • Client was not reached for interview

  • Client refused all interviews


4. [CHILD ONLY] Was the respondent the child or the caregiver?



  • Child

  • Caregiver

BEHAVIORAL HEALTH DIAGNOSES

BEHAVIORAL HEALTH DIAGNOSES information is collected by grantee staff at BASELINE, REASSESSMENT and DISCHARGE, even when an assessment interview is not conducted.


  1. Was the client screened or assessed by your program for trauma-related experiences?


  • Yes

  • No

  • DON’T KNOW


1a. [IF QUESTION 1 IS NO] Please select why:


  • No time during interview

  • No training around trauma screening/disclosure

  • No institutional/organizational policy around screening

  • No referral network and/or infrastructure for trauma services currently available

  • Other


1b. [IF QUESTION 1 IS YES] Was the screen positive?


  • Yes

  • No

  • DON’T KNOW


  1. Did the client have a positive suicide screen?


  • Yes

  • No

  • DON’T KNOW


2a. [IF QUESTION 2 IS YES] Was a suicidal safety plan developed?


  • Yes

  • No

  • DON’T KNOW


2b. [IF QUESTION 2 IS YES] Was access to lethal means assessed?


  • Yes

  • No

  • DON’T KNOW



  1. Behavioral Health Diagnoses

Please indicate the client’s current behavioral health diagnoses using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes listed below, as made by a clinician. Please note that some substance use disorder ICD-10-CM codes have been crosswalked to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) descriptors. Select up to three behavioral health diagnoses from the mental health, Z-codes, and substance use diagnoses below.

If no mental health diagnosis, select reason:

  • No clinician assessment

  • High risk factors requiring intervention and not yet meeting criteria for a DSM/ICD diagnosis

  • Only met criteria for a “Z” code

  • Other (please specify_______________________________________)


MENTAL HEALTH DIAGNOSES

 Diagnosed?

Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders


F20 – Schizophrenia

F21 – Schizotypal disorder

F22 – Delusional disorder

F23 – Brief psychotic disorder

F24 – Shared psychotic disorder

F25 – Schizoaffective disorders

F28 – Other psychotic disorder not due to a substance or known physiological condition

F29 – Unspecified psychosis not due to a substance or known physiological condition

Mood [affective] disorders


F30 – Manic episode

F31 – Bipolar disorder

F32 – Major depressive disorder, single episode

F33 – Major depressive disorder, recurrent

F34 – Persistent mood [affective] disorders

F39 – Unspecified mood [affective] disorder

Phobic Anxiety and Other Anxiety Disorders


F40 – Phobic anxiety disorders

F40.00 – Agoraphobia, unspecified

F40.01 – Agoraphobia with panic disorder

F40.02 – Agoraphobia without panic disorder

F40.1 – Social phobias (Social anxiety disorder)

F40.10 – Social phobia, unspecified

F40.11 – Social phobia, generalized

F40.2 – Specific (isolated) phobias

F41 – Other anxiety disorders

F41.0 – Panic disorder

F41.1 – Generalized anxiety disorder

Obsessive-compulsive disorders


F42 – Obsessive-compulsive disorder

F42.2 – Obsessive-compulsive disorder with mixed obsessional thoughts and acts

F42.3 – Hoarding disorder

F42.4 – Excoriation (skin-picking) disorder

F42.8 – Other obsessive-compulsive disorder

F42.9 – Obsessive-compulsive disorder, unspecified

MENTAL HEALTH DIAGNOSES

 Diagnosed?

Reaction to severe stress and adjustment disorders


F43 – Acute stress disorder; reaction to severe stress, and adjustment disorders

F43.10 – Post traumatic stress disorder, unspecified

F43.2 – Adjustment disorders

F44 – Dissociative and conversion disorders

F44.81 – Dissociative identity disorder

F45 – Somatoform disorders

F45.22 – Body dysmorphic disorder

F48 – Other non-psychotic mental disorders

Behavioral syndromes associated with physiological disturbances and physical factors


F50 – Eating disorders

F51 – Sleep disorders not due to a substance or known physiological condition

Disorders of adult personality and behavior


F60.0 – Paranoid personality disorder

F60.1 – Schizoid personality disorder

F60.2 – Antisocial personality disorder

F60.3 – Borderline personality disorder

F60.4 – Histrionic personality disorder

F60.5 – Obsessive-compulsive personality disorder

F60.6 – Avoidant personality disorder

F60.7 – Dependent personality disorder

F60.8 – Other specific personality disorders

F60.9 – Personality disorder, unspecified

F63.3 – Trichotillomania

F70–F79 – Intellectual disabilities

F80–F89 – Pervasive and specific developmental disorders

Behavioral and emotional disorders with onset usually occurring in childhood and adolescence


F90 – Attention-deficit hyperactivity disorders

F91 – Conduct disorders

F93 – Emotional disorders with onset specific to childhood

F93.0 – Separation anxiety disorder of childhood

F94 – Disorders of social functioning with onset specific to childhood or adolescence

F94.0 – Selective mutism

F94.1 – Reactive attachment disorder of childhood

F94.2 – Disinhibited attachment disorder of childhood

F95 – Tic disorder

F98 – Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence

F99 – Unspecified mental disorder



Z codes – Persons with potential health hazards related to socioeconomic and psychosocial circumstances

 Diagnosed?

Z55 – Problems related to education and literacy

Z56 – Problems related to employment and unemployed

Z57 – Occupational exposure to risk factors

Z59 – Problems related to housing and economic circumstances

Z60 – Problems related to social environment

Z62 – Problems related to upbringing

Z codes – Persons with potential health hazards related to socioeconomic and psychosocial circumstances

 Diagnosed?

Z63 – Other problems related to primary support group, including family circumstances

Z64 – Problems related to certain psychological circumstances

Z65 – Problems related to other psychosocial circumstances


SUBSTANCE USE DIAGNOSES

 Diagnosed?

Alcohol related disorders

 

F10.10 – Alcohol abuse, uncomplicated

F10.11 – Alcohol abuse, in remission

F10.20 – Alcohol dependence, uncomplicated

F10.21 – Alcohol dependence, in remission

F10.9 – Alcohol use, unspecified

Opioid related disorders

 

F11.10 – Opioid abuse, uncomplicated,

F11.11 – Opioid abuse, in remission

F11.20 – Opioid dependence, uncomplicated

F11.21 – Opioid dependence, in remission

F11.9 – Opioid use, unspecified

Cannabis related disorders

 

F12.10 – Cannabis abuse, uncomplicated

F12.11 – Cannabis abuse, in remission

F12.20 – Cannabis dependence, uncomplicated

F12.21 – Cannabis dependence, in remission

F12.9 – Cannabis use, unspecified

Sedative, hypnotic, or anxiolytic related disorders

 

F13.10 – Sedative, hypnotic, or anxiolytic abuse, uncomplicated

F13.11 – Sedative, hypnotic, or anxiolytic abuse, in remission

F13.20 – Sedative, hypnotic, or anxiolytic dependence, uncomplicated

F13.21 – Sedative, hypnotic, or anxiolytic dependence, in remission

F13.9 – Sedative, hypnotic, or anxiolytic-related use, unspecified

Cocaine related disorders

 

F14.10 – Cocaine abuse, uncomplicated

F14.11 – Cocaine abuse, in remission

F14.20 – Cocaine dependence, uncomplicated

F14.21 – Cocaine dependence, in remission

F14.9 – Cocaine use, unspecified

Other stimulant related disorders

 

F15.10 – Other stimulant abuse, uncomplicated

F15.11 – Other stimulant abuse, in remission

F15.20 – Other stimulant dependence, uncomplicated

F15.21 – Other stimulant dependence, in remission

F15.9 – Other stimulant use, unspecified

Hallucinogen related disorders

 

F16.10 – Hallucinogen abuse, uncomplicated

F16.11 – Hallucinogen abuse, in remission

F16.20 – Hallucinogen dependence, uncomplicated

F16.21 – Hallucinogen dependence, in remission

F16.9 – Hallucinogen use, unspecified

SUBSTANCE USE DIAGNOSES

 Diagnosed?

Inhalant related disorders

 

F18.10 – Inhalant abuse, uncomplicated

F18.11 – Inhalant abuse, in remission

F18.20 – Inhalant dependence, uncomplicated

F18.21 – Inhalant dependence, in remission

F18.9 – Inhalant use, unspecified

Other psychoactive substance related disorders

 

F19.10 – Other psychoactive substance abuse, uncomplicated

F19.11 – Other psychoactive substance abuse, in remission

F19.20 – Other psychoactive substance dependence, uncomplicated

F19.21 – Other psychoactive substance dependence, in remission

F19.9 – Other psychoactive substance use, unspecified

Nicotine dependence

 

F17.20 – Nicotine dependence, unspecified

F17.21 – Nicotine dependence, cigarettes



For BASELINE:

  • If an interview WAS conducted, go to Demographic Data.

  • If an interview WAS NOT conducted, STOP HERE.



For REASSESSMENT or CLINICAL DISCHARGE:

  • If an interview WAS conducted, go to Section A.

  • If an interview WAS NOT conducted, go to Section H.



DEMOGRAPHIC DATA

DEMOGRAPHIC DATA are only collected at BASELINE. If this is NOT a BASELINE, go to Section A.

  1. What do you consider yourself to be? [READ CHOICES.]

  • Male

  • Female

  • Transgender (Male to Female)

  • Transgender (Female to Male)

  • Gender non-conforming

  • OTHER (Specify) ______________________________

  • REFUSED

  1. Do you think of yourself as…

  • Straight or Heterosexual

  • Homosexual (Gay Or Lesbian)

  • Bisexual

  • Queer

  • Pansexual

  • Questioning

  • Asexual

  • Something Else? Please Specify ___________________________________

  • REFUSED

  1. Are you [is your child] Hispanic, Latino/a, or of Spanish origin?

  • Yes

  • No [SKIP TO QUESTION 4.]

  • REFUSED [SKIP TO QUESTION 4.]

3a. [IF QUESTION 3 IS YES] What ethnic group do you [your child] consider yourself [themselves]? You may indicate more than one.

  • Central American

  • Cuban

  • Dominican

  • Mexican

  • Puerto Rican

  • South American

  • OTHER (Specify)________________________

  • REFUSED






  1. What is your [your child’s] race? You may indicate more than one.

  • Black or African American

  • White

  • American Indian

  • Alaska Native

  • South Asian

  • Chinese

  • Filipino

  • Japanese

  • Korean

  • Vietnamese

  • Other Asian

  • Native Hawaiian

  • Guamanian or Chamorro

  • Samoan

  • Other Pacific Islander

  • OTHER (Specify)___________________________

  • REFUSED


  1. [IF CLIENT 5 YEARS OLD OR OLDER] Do you [does your child] speak a language other than English at home?

  • Yes

  • No

  • NOT APPLICABLE


5a. [IF CLIENT 5 YEARS OLD OR OLDER] [IF QUESTION 5 IS YES] What is this language?


  • Spanish

  • OTHER (Specify) ____________________________

  1. [ADULT ONLY] Have you ever served in the Armed Forces, the Reserves, or the National Guard?

  • Yes

  • No [GO TO SECTION A.]

  • DON’T KNOW [GO TO SECTION A.]

  • NOT APPLICABLE [GO TO SECTION A.]

  1. [ADULT ONLY] [IF QUESTION 6 IS YES] Are you currently serving on active duty in the Armed Forces, the Reserves, or the National Guard?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW

A. FUNCTIONING

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

  • Excellent

  • Very Good

  • Good

  • Fair

  • Poor

  • NO RESPONSE/REFUSED

  1. To provide the best mental health and related services, we need to know how well you were [your child was] able to deal with everyday life during the past 30 [thirty] days. Please indicate your [your child’s] response to each of the following statements:

[READ EACH STATEMENT TO THE CLIENT OR CAREGIVER, FOLLOWED BY RESPONSE OPTIONS OF YES OR NO]


During the past 30 [thirty] days ….

Yes

No

NO RESPONSE/ REFUSED

  1. I am [my child is] handling daily life.

  1. I am [my child is] able to deal with unexpected events in my [their] life.

  1. I [my child does] get along with friends and other people.

  1. I [my child does] get along with family members.

  1. I do [my child does] well in social situations.

  1. I do [my child does] well in school and/or work.

  1. I have [my child has] had a safe place to live.

  1. The following questions ask about how you have [your child has] been feeling during the past 30 [thirty] days. Please indicate your [your child’s] response to each question:

During the past 30 [thirty] days, did you [your child] feel …

Yes

No

NO RESPONSE/ REFUSED

  1. Nervous?

  1. Hopeless?

  1. Restless or fidgety?

  1. So depressed that nothing could cheer you [your child] up?

  1. That everything was an effort?

  1. Worthless?

  1. Bothered by psychological or emotional problems?














B. STABILITY IN HOUSING

  1. In the past 30 [thirty] days, have you [has your child] …

Yes

No

NO RESPONSE/ REFUSED

  1. Been homeless?

  1. Spent time in a hospital for mental health care?

  1. Spent time in a facility for detox/inpatient treatment for a substance abuse disorder?

  1. Spent time in a correctional facility (e.g., jail, prison, [juvenile] facility)?

  1. Gone to an emergency room for a mental health or emotional problem?

  1. Been satisfied with the conditions of your living space?

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

[DO NOT READ RESPONSE OPTIONS TO THE CLIENT. SELECT ONLY ONE.]

  • PRIVATE RESIDENCE

  • FOSTER HOME

  • RESIDENTIAL CARE

  • CRISIS RESIDENCE

  • RESIDENTIAL TREATMENT CENTER

  • INSTITUTIONAL SETTING

  • JAIL/CORRECTIONAL FACILITY

  • HOMELESS/SHELTER

  • OTHER (SPECIFY) ______________________

  • DON’T KNOW


C. EDUCATION AND EMPLOYMENT

    1. Are you [is your child] currently enrolled in school or a job training program?

  • Yes

  • No

  • NO RESPONSE/REFUSED

    1. [ADULT ONLY] What is the highest level of education you have finished, whether or not you received a degree? [SELECT ONLY ONE]

  • LESS THAN 12TH GRADE

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

  • VOCATIONAL/TECHNICAL (VOC/TECH) DIPLOMA

  • SOME COLLEGE OR UNIVERSITY

  • BACHELOR’S DEGREE (BA, BS)

  • GRADUATE WORK/GRADUATE DEGREE

  • REFUSED

  • DON’T KNOW

    1. [ADULT ONLY] Are you currently employed? [SELECT ONLY ONE]

  • Employed full-time (35+ HOURS PER WEEK)

  • 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

  • DON’T KNOW

    1. In the past 30 [thirty] days, did you have enough money to meet your [your child’s] needs?

  • Yes

  • No

  • NO RESPONSE/REFUSED

D. CRIME AND CRIMINAL JUSTICE STATUS

  1. In the past 30 [thirty] days, have you [has your child]…

Yes

No

NO RESPONSE/ REFUSED

1a. Been arrested?

1b. Spent time in jail or a correctional facility or been on probation?




If this is a BASELINE assessment, go to Section F.



If this is a REASSESSMENT or a CLINICAL DISCHARGE assessment, go to Section E.

Section E data is collected only for the REASSESSMENT interview and the CLINICAL DISCHARGE assessment.



E. PERCEPTION OF CARE

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

[READ EACH STATEMENT TO THE CLIENT OR CAREGIVER, FOLLOWED BY RESPONSE OPTIONS OF YES OR NO]

Statement

Yes

No

NO RESPONSE/ REFUSED

  1. Staff here believe that I [my child] can grow, change, and recover.

  1. I [my child] felt free to complain.

  1. I [my child] was given information about my [my child’s] rights.

  1. Staff encouraged me [my child] to take responsibility for how I [they] live my [their] life.

  1. Staff told me [my child] what side effects to watch out for.

  1. Staff respected my [my child’s] wishes about who is and who is not to be given information about my [my child’s] treatment.

  1. Staff were sensitive to my [my child’s] cultural background (e.g., race, religion, language).

  1. Staff helped me [my child] obtain the information I [my child] needed so that I [my child] could take charge of managing my [their] illness.

  1. I [my child] was encouraged to use consumer-run programs (support groups, drop-in centers, crisis phone line, etc.).

  1. I [my child] felt comfortable asking questions about my [their] treatment and medication.

  1. I [my child], not staff, decided my [my child’s] treatment goals.

  1. I [my child] like[s] the services received here.

  1. I [my child] would still get services from this agency if there were other choices.

  1. I [my child] would recommend this agency to a friend or family member.


Question 2 should be answered by grantee staff at REASSESSMENT and CLINICAL DISCHARGE.

  1. Indicate which grantee staff administered section E to the client for this interview:

  • Administrative staff

  • Care coordinator

  • Case manager

  • Clinician providing direct services

  • Clinician not providing direct services

  • Consumer/peer

  • Data collector/evaluator

  • Family advocate

  • Other (Specify)

F. SOCIAL CONNECTEDNESS

    1. Please indicate YES or NO for each of the following statements. Please answer for relationships with persons other than your [your child’s] mental health provider(s) over the past 30 [thirty] days.

[READ EACH STATEMENT TO THE CLIENT OR CAREGIVER, FOLLOWED BY RESPONSE OPTIONS OF YES OR NO]

Statement

Yes

No

NO RESPONSE/ REFUSED

  1. I am [my child is] happy with my [their] friendships.

  1. I have [my child has] people with whom I [they] can do enjoyable things.

  1. I feel [my child feels] that I [they] belong in the community.

  1. In a crisis, I [my child] would have the support needed from family or friends.

  1. I have [my child has] family or friends that are supportive of my [their] recovery.

  1. I [my child] generally accomplish[es] what I [they] set out to do.



If your program does not require Section G and this is a …

BASELINE ASSESSMENT, stop now – the interview is completed.

REASSESSMENT interview or CLINICAL DISCHARGE – go to Section H.

IF YOUR PROGRAM DOES REQUIRE SECTION G, and this is a …

BASELINE interview – go to Section G for your program and then stop.

REASSESSMENT interview or CLINICAL DISCHARGE interview –
go to Section G for your program, and then to Section H.




G. PROGRAM-SPECIFIC QUESTIONS

You are NOT responsible for collecting data on ALL Section G questions. Only complete the Section G which is specific to your program.

Your GPO will provide guidance on which specific Section G questions you are to complete. If you have any questions, please contact your GPO.



G1. ASSISTED OUTPATIENT TREATMENT


G2. LAW ENFORCEMENT AND BEHAVIORAL HEALTH PARNTERSHIPS FOR EARLY DIVERSION


G3. PROMOTING THE INTEGRATION OF PRIMARY AND BEHAVIORAL HEALTH CARE


G4. MINORITY AIDS – SERVICE INTEGRATION


G5. HEALTHY TRANSITIONS


G6. ASSERTIVE COMMUNITY TREATMENT


G7. CLINICAL HIGH RISK FOR PSYCHOSIS


G8. CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS


G9. NATIONAL CHILD TRAUMATIC STRESS INITIATIVE – CATEGORY 3







G1. ASSISTED OUTPATIENT TREATMENT
PROGRAM-SPECIFIC QUESTIONS


  1. In the past 30 [thirty] days, have you taken your psychiatric medication(s) as prescribed to you?

  • Yes

  • No

  • REFUSED

  • NOT APPLICABLE


Question 2 should be answered by grantee staff at REASSESSMENT and CLINICAL DISCHARGE.


  1. In the past 30 [thirty] days, has the client followed their treatment plan?

  • Yes

  • No

  • Refused

  • Not applicable



If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.



G2. LAW ENFORCEMENT AND BEHAVIORAL HEALTH PARNTERSHIPS FOR EARLY DIVERSION
PROGRAM-SPECIFIC QUESTIONS

Questions 1 and 2 should be answered by grantee staff at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.

1. Was the client referred to mental health services?

  • Yes No


1a. [IF QUESTION 1 IS YES] Did they receive mental health services?


  • Yes No

2. Was the client referred to substance use disorder services?

  • Yes No


2a. [IF QUESTION 2 IS YES] Did they receive substance use disorder services?


  • Yes No


Question 3 should be answered by the client only at REASSESSMENT and CLINICAL DISCHARGE.

  1. Has this program helped you avoid further contact with the police and criminal justice system?

  • Yes

  • No

  • NO RESPONSE/REFUSED



If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.


G3. PROMOTING THE INTEGRATION OF PRIMARY AND BEHAVIORAL HEALTH CARE
PROGRAM-SPECIFIC QUESTIONS

Question 1 should be answered by the client at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.


  1. In the past 30 [thirty] days, have you ….

Yes

No

REFUSED

1a. Been to the emergency room for a physical healthcare problem?

1b. Been hospitalized overnight for a physical healthcare problem?



Program-Specific Health Items should be answered by grantee staff at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.

  1. Health measurements

    2a.

    Systolic blood pressure

     

    mmHg

    2b.

    Diastolic blood pressure

     

    mmHg

    2c.

    Weight

     

    kg

    2d.

    Height

     

    cm

    2e.

    Breath CO for smoking status

     

    ppm

  2. Blood test results. Please choose one of b or c only.

3a. Date of blood draw: |____|____| / |____|____| / |____|____|____|____|
 MONTH DAY YEAR

3b.

Fasting plasma glucose

 

mg/dL

3c.

HgBA1c

 

%

3d.

Total Cholesterol

 

mg/dL

3e.

LDL Cholesterol

 

mg/dL



If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.



G4. MINORITY AIDS – SERVICE INTEGRATION
PROGRAM-SPECIFIC QUESTIONS

Questions should be answered by the client at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.



1. Did the program provide an HIV test?

  • Yes

  • No [SKIP TO QUESTION 2.]

  • REFUSED [SKIP TO QUESTION 2.]

  • DON’T KNOW [SKIP TO QUESTION 2.]

1a. [IF QUESTION 1 IS YES] What was the result?

  • Positive

  • Negative [SKIP TO QUESTION 2.]

  • Indeterminate [SKIP TO QUESTION 2.]

  • REFUSED [SKIP TO QUESTION 2.]

  • DON’T KNOW [SKIP TO QUESTION 2.]

1b. [IF QUESTION 1a IS POSITIVE] Were you connected to HIV treatment services?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW

2. Did the program provide a Hepatitis B (HBV) test?

  • Yes

  • No [SKIP TO QUESTION 3.]

  • REFUSED [SKIP TO QUESTION 3.]

  • DON’T KNOW [SKIP TO QUESTION 3.]

2a. [IF QUESTION 2 IS YES] What was the result?

  • Positive

  • Negative [SKIP TO QUESTION 3.]

  • Indeterminate [SKIP TO QUESTION 3.]

  • REFUSED [SKIP TO QUESTION 3.]

  • DON’T KNOW [SKIP TO QUESTION 3.]

2b. [IF QUESTION 2a IS POSITIVE] Were you connected to HBV treatment services?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW


3. Did the program provide a Hepatitis C (HCV) test?

  • Yes

  • No [SKIP TO QUESTION 4.]

  • REFUSED [SKIP TO QUESTION 4.]

  • DON’T KNOW [SKIP TO QUESTION 4.]

3a. [IF QUESTION 3 IS YES] What was the result?

  • Positive

  • Negative [SKIP TO QUESTION 4.]

  • Indeterminate [SKIP TO QUESTION 4.]

  • REFUSED [SKIP TO QUESTION 4.]

  • DON’T KNOW [SKIP TO QUESTION 4.]

3b. [IF QUESTION 3a IS POSITIVE] Were you connected to HCV treatment services?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW

4. Did you receive a referral form from [INSERT GRANTEE NAME] to medical care?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW

5. Have you been prescribed an Antiretroviral Medication (ART)?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW

5a. [IF QUESTION 5 IS YES] In the past 30 [thirty] days, how often have you taken your ART as prescribed to you?

  • Always

  • Usually

  • Sometimes

  • Rarely

  • Never

  • Refused

  • DON’T KNOW

  • NOT APPLICABLE [IF THE PRESCRIPTION WAS GIVEN FOR THE FIRST TIME AT THIS APPOINTMENT, SELECT NOT APPLICABLE.]


If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.


G5. HEALTHY TRANSITIONS
PROGRAM-SPECIFIC QUESTIONS


Questions should be answered by grantee staff at BASELINE, REASSESSMENT and CLINICAL DISCHARGE.

1. Was the client referred to mental health services?

  • YES NO


1a. [IF QUESTION 1 IS YES] Did they receive mental health services?


  • YES NO

2. Was the client referred to substance use disorder services?

  • YES NO


2a. [IF QUESTION 2 IS YES] Did they receive substance use disorder services?

  • YES NO


If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.


G6. ASSERTIVE COMMUNITY TREATMENT
PROGRAM-SPECIFIC QUESTIONS


Questions should be answered by the client at REASSESSMENT and CLINICAL DISCHARGE. If this is a BASELINE assessment, stop here.

  1. How often does a member of your team interact with you?

  • At least daily

  • At least weekly

  • At least monthly

  • Never

  • REFUSED

  • DON’T KNOW

  1. If I need to talk with someone on my team, I know who to call.

  • Yes

  • No

  • REFUSED

  • NOT APPLICABLE



If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.



G7. CLINICAL HIGH RISK FOR PSYCHOSIS
PROGRAM-SPECIFIC QUESTIONS

Question 1 is answered by grantee staff at REASSESSMENT and CLINICAL DISCHARGE. If this is a BASELINE assessment, stop here.

  1. Has the client experienced an episode of psychosis since their last interview?

  • Yes

  • No

  • DON’T KNOW

1a. [IF QUESTION 1 IS YES] Please indicate the approximate date that the client initially experienced psychosis.

|___|___| / |___|___|___|___|
MONTH YEAR

1b. [IF QUESTION 1 IS YES] Was the client referred to services?

  • Yes

  • No

  • DON’T KNOW

1c. [IF QUESTION 1b IS YES] Please indicate the date that the client received services/treatment.

|___|___| / |___|___|___|___| DON’T KNOW
MONTH YEAR



If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.


G8. CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS
PROGRAM-SPECIFIC QUESTIONS

Questions should be answered by grantee staff at BASELINE, REASSESSMENT and CLINICAL DISCHARGE.

    1. During the past 30 [thirty] days, did the client receive the following services?

      1. Crisis mental health services Yes No

      2. Screening, assessment, diagnosis Yes No

      3. Patient-centered treatment planning Yes No

      4. Outpatient mental health services Yes No

      5. Physical health screening/monitoring Yes No

      6. Targeted case management Yes No

      7. Psychiatric rehabilitation services Yes No

      8. Peer support services Yes No

      9. Family psychoeducation and support Yes No

      10. Services for veterans and military members Yes No



    1. Health measurements:

2a.

Systolic blood pressure

 

mmHg

2b.

Diastolic blood pressure

 

mmHg

2c.

Weight

 

kg

2d.

Height

 

cm



If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.









G9. NATIONAL CHILD TRAUMATIC STRESS INITIATIVE – CATEGORY 3
PROGRAM-SPECIFIC QUESTIONS

Questions should be answered by the client or caregiver at REASSESSMENT and CLINICAL DISCHARGE. If this is a BASELINE assessment, stop here.


[READ EACH STATEMENT BELOW TO THE CLIENT OR CAREGIVER AND NOTE RESPONSE.]

Statement

Yes

No

NO RESPONSE/REFUSED

NOT APPLICABLE

1. As a result of treatment and services received, my [my child’s] trauma and/or loss experiences were identified and addressed.

2. As a result of treatment and services received for trauma and/or loss experiences, my [my child’s] problem behaviors/symptoms have decreased.


If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.



H. SERVICES RECEIVED AND CLINICAL DISCHARGE STATUS

Question 1 is answered by grantee staff at REASSESSMENT and CLINICAL DISCHARGE only.


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


|___|___| / |___|___|___|___|

MONTH YEAR

Identify all the services your grant project provided to the client during their participation in the program. This includes grant-funded and non-grant funded services.

Core Services

Provided


Unknown

Service Not Available

Yes

No

  1. Screening

  1. Assessment

  1. Treatment Planning or Review

  1. Psychopharmacological Services

  1. Mental Health Services

  1. Co-occurring Services

  1. Case Management

  1. Trauma-specific Services

  1. Was the client referred to another provider for any of the above core services?


Support Services

Provided


Unknown

Service Not Available

Yes

No

1j. Medical Care

  1. Employment Services

  1. Family Services

  1. Child Care

  1. Transportation

  1. Education Services

  1. Housing Support

  1. Social Recreational Activities

  1. Consumer-Operated Services

  1. HIV Testing

  1. Was the client referred to another provider for any of the above support services?




Questions 2 and 3 are answered by grantee staff at CLINICAL DISCHARGE only.

  1. On what date was the client discharged?

|___|___| / |___|___|___|___|
MONTH YEAR

  1. What is the client’s discharge status?

  • Mutually agreed cessation of treatment

  • Withdrew from/refused treatment

  • No contact within 90 days of last encounter

  • Clinically referred out

  • Death

  • Other (Specify)



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleCMHS NOMs Client-Level Services Tool for Adults
SubjectCMHS NOMs Client-Level Services Tool for Adults revised March 2019
AuthorSubstance Abuse and Mental Health Services Administration
File Modified0000-00-00
File Created2022-08-17
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