Form CSAT GPRA TOOL CSAT GPRA TOOL CSAT GPRA TOOL

Form Approved
OMB No. 0930-0208
Expiration Date: 03/31/2025

Substance Abuse and Mental Health Services Administration
(SAMHSA)
Center for Substance Abuse Treatment (CSAT)
Government Performance and Results Act (GPRA)
Client Outcome Measures for Discretionary Programs
August 2022

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.

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Table of Contents
A.
A.
B.
C.
D.
E.
F.
G.
H1.
H2.
H3.
H4.
H5.
H6.
H7.
H8.
H9.
H10.
I.
J.
K.

RECORD MANAGEMENT .......................................................................................................................... 4
RECORD MANAGEMENT - DEMOGRAPHICS........................................................................................ 5
SUBSTANCE USE AND PLANNED SERVICES ....................................................................................... 8
LIVING CONDITIONS ............................................................................................................................... 15
EDUCATION, EMPLOYMENT, AND INCOME ...................................................................................... 16
LEGAL ......................................................................................................................................................... 18
MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY ....................... 19
SOCIAL CONNECTEDNESS ..................................................................................................................... 21
PROGRAM SPECIFIC QUESTIONS .......................................................................................................... 22
PROGRAM SPECIFIC QUESTIONS ......................................................................................................... 23
PROGRAM SPECIFIC QUESTIONS ......................................................................................................... 24
PROGRAM SPECIFIC QUESTIONS ......................................................................................................... 25
PROGRAM SPECIFIC QUESTIONS ......................................................................................................... 26
PROGRAM SPECIFIC QUESTIONS ......................................................................................................... 27
PROGRAM SPECIFIC QUESTIONS ......................................................................................................... 29
PROGRAM SPECIFIC QUESTIONS ......................................................................................................... 33
PROGRAM SPECIFIC QUESTIONS ......................................................................................................... 34
PROGRAM SPECIFIC QUESTIONS ......................................................................................................... 35
FOLLOW-UP STATUS ............................................................................................................................... 37
DISCHARGE STATUS ............................................................................................................................... 38
SERVICES RECEIVED UNDER GRANT FUNDING .............................................................................. 39

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3

A.

RECORD MANAGEMENT

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 [FOR SELECT PROGRAMS]
→ → → Did you conduct a follow-up interview?
[IF NO, GO DIRECTLY TO SECTION I.]

Yes

No

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

Yes

No

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

Yes

No

Interview Date

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

4

A.

RECORD MANAGEMENT - DEMOGRAPHICS [ASKED ONLY AT INTAKE/BASELINE.]

1.

What is your birth month and year?
|____|____| / |____|____|____|____|
Month
Year
REFUSED

2.

What do you consider yourself to be?
Male
Female
Transgender (Male to Female)
Transgender (Female to Male)
Gender non-conforming
Other (SPECIFY) _____________
REFUSED

3.

Are you Hispanic, Latino/a, or of Spanish origin?
Yes
No
[SKIP TO QUESTION 4]
REFUSED [SKIP TO QUESTION 4]
3a. 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

4.

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
5

5.

Do you speak a language other than English at home?
 Yes
 No
 REFUSED

[SKIP TO QUESTION 6]
[SKIP TO QUESTION 6]

5a. What is this language?
 Spanish
 Other (SPECIFY) ___________
6.

Do you think of yourself as… [YOU MAY INDICATE MORE THAN ONE.]
Straight Or Heterosexual
Homosexual (Gay Or Lesbian)
Bisexual
Queer, Pansexual, And/Or Questioning
Asexual
Other (SPECIFY) ___________________________________
REFUSED

7.

What is your relationship status?
Married
Single
Divorced
Separated
Widowed
In a relationship
In multiple relationships
REFUSED

8.

Are you currently pregnant?
Yes
No
Do not know
REFUSED

9.

Do you have children? [Refers to children both living and/or who may have died]
Yes
No
REFUSED
9a.

How many children under the age of 18 do you have?
|____|____|

9b.

[SKIP TO QUESTION 10]
[SKIP TO QUESTION 10]

REFUSED

Are any of your children, who are under the age of 18, living with someone else due to a court’s
intervention? [THE VALUE IN ITEM A9b CANNOT EXCEED THE VALUE IN A9a.]
Yes
Number of children removed from client’s care |____|____|
No
[SKIP TO QUESTION 10]
REFUSED [SKIP TO QUESTION 10]
6

9c.

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 A9c CANNOT EXCEED THE VALUE IN A9a.]
Yes
Number of children with whom the client has been reunited |____|____|
No
REFUSED

10.

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]
REFUSED

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

7

B.

SUBSTANCE USE AND PLANNED SERVICES

1. USING THE TABLE BELOW, PLEASE INDICATE THE FOLLOWING:
A. THE NUMBER OF DAYS, IN THE PAST 30 DAYS, THAT THE CLIENT REPORTS USING A
SUBSTANCE.
[DO NOT READ TO CLIENT] 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. If the client refuses to answer the
question, then select “REFUSED”.
B. THE ROUTE BY WHICH THE SUBSTANCE IS USED.
[DO NOT READ TO CLIENT] Mark one route only for each substance used. 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 substance, and how do you take the substance?
REFUSED
B. Route
A. Number of
Days Used

a. Alcohol
1. Alcohol
2. Other (SPECIFY)

1.
Oral
4.
Smoking

2.
Intranasal

5.
6.
Non-IV Injection
Intravenous (IV) Injection
0.
Other

|___|___|
|___|___|

|___|
|___|

|___|___|
|___|___|

|___|
|___|

b. Opioids
1. Heroin
2. Morphine
3. Fentanyl (Prescription Diversion Or
Illicit Source)
4. Dilaudid
5. Demerol
6. Percocet
7. Codeine
8. Tylenol 2, 3, 4
9. OxyContin/Oxycodone
10. Non-prescription methadone
11. Non-prescription buprenorphine
12. Other (SPECIFY)

|___|___|

|___|

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c. Cannabis
1. Cannabis (Marijuana)
2. Synthetic Cannabinoids

|___|___|
|___|___|

|___|
|___|

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3.
Vaping

B. Route
A. Number of
Days Used

3. Other (SPECIFY)
d. Sedative, Hypnotic, or Anxiolytics
1. Sedatives
2. Hypnotics
3. Barbiturates
4. Anxiolytics/Benzodiazepines
5. Other (SPECIFY)

|___|___|

1.
Oral
4.
Smoking

2.
Intranasal

5.
6.
Non-IV Injection
Intravenous (IV) Injection
0.
Other

|___|

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|___|
|___|
|___|
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|___|
|___|
|___|
|___|
|___|
|___|

|___|___|

|___|

e. Cocaine
1. Cocaine
2. Crack
3. Other (SPECIFY)
f. Other Stimulants
1. Methamphetamine
2. Stimulant medications
3. Other (SPECIFY)
g. Hallucinogens & Psychedelics
1. PCP
2. MDMA
3. LSD
4. Mushrooms
5. Mescaline
6. Salvia
7. DMT
8. Other (SPECIFY)
h. Inhalants
1. Inhalants
2. Other (SPECIFY)
i. Other Psychoactive Substances
1. Non-prescription GHB
2. Ketamine
3. MDPV/Bath Salts
4. Kratom
5. Khat
6. Other tranquilizers
7. Other downers
8. Other sedatives
9. Other hypnotics
10. Other (SPECIFY)
j. Tobacco and Nicotine
1. Tobacco

9

3.
Vaping

B. Route
A. Number of
Days Used

2. Nicotine (Including Vape Products)
3. Other (SPECIFY)

|___|___|
|___|___|

1.
Oral
4.
Smoking

2.
Intranasal

3.
Vaping

5.
6.
Non-IV Injection
Intravenous (IV) Injection
0.
Other

|___|
|___|

2. Have you been diagnosed with an alcohol use disorder, if so 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
3. Have you been diagnosed with an opioid use disorder, if so 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
4. Have you been diagnosed with a stimulant use disorder, if so which evidence-based interventions did you
receive for the treatment of this disorder in the past 30 days? [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 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
5. Have you been diagnosed with a tobacco use disorder, if so 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
6. 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, SKIP TO QUESTION 8]
REFUSED [SKIP TO QUESTION 8]
10

7.

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

8.

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]

9.

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

10.

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]
10a.

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. PLEASE INDICATE ALL THAT APPLY.
SELF-REPORTED

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
11

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SELF-REPORTED
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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

o

NONE OF THE ABOVE

12

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[FOLLOW-UP AND DISCHARGE INTERVIEWS: GO 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?
Yes
No
11a.

[SKIP TO QUESTION 12]

Did the client screen positive for co-occurring mental health and substance use
disorders?
Yes
No

11b.

[IF YES TO QUESTION 11a] Was the client referred for further assessment for a co-occurring
mental health and substance use disorder?
Yes
No

13

12.

PLANNED SERVICES PROVIDED UNDER GRANT FUNDING [REPORTED BY PROGRAM STAFF
ONLY AT INTAKE/BASELINE.]

Identify the services you plan to provide to the client
during the client’s course of treatment/recovery. [MARK

Case Management Services
1.

ONLY THE CIRCLE CORRESPONDING TO THE PLANNED
SERVICE THAT WILL BE PROVIDED UNDER THE CURRENT
GRANT. MARK ALL THAT APPLY IN EACH SECTION.]

2.
3.

Modality
[SELECT AT LEAST ONE MODALITY.]

1.
2.
3.

4.
5.
6.

7.
8.

9.
10.
11.

4.
5.
6.

Case Management
Intensive Outpatient Treatment
Inpatient/Hospital (Other Than Withdrawal
Management)
Outpatient Therapy
Outreach
Medication
A.
Methadone
B.
Buprenorphine
C.
Naltrexone – Short Acting
D.
Naltrexone – Long Acting
E.
Disulfiram
F.
Acamprosate
G. Nicotine Replacement
H. Bupropion
I.
Varenicline
Residential/Rehabilitation
Withdrawal Management (Select Only One)
A. Hospital Inpatient
B. Free Standing Residential
C. Ambulatory Detoxification
After Care
Recovery Support
Other (Specify)________________________

7.
8.
9.
10.

Medical Services

1.
2.
3.
4.
5.
6.
7.
8.

Medical Care
Alcohol/Drug Testing
OB/GYN Services
HIV/AIDS Medical Support & Testing
Dental Care
Viral Hepatitis Medical Support & Testing
Other STI Support & Testing
Other Medical Services
(Specify) ____________________________

After Care Services

1.
2.
3.
4.
5.
6.

[SELECT AT LEAST ONE SERVICE.]
Treatment Services
[SBIRT GRANTS: YOU MUST PROVIDE AT
LEAST ONE OF THE TREATMENT
SERVICES NUMBERED 1 THROUGH 4.]

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Family Services (E.g. Marriage Education,
Parenting, Child Development Services)
Child Care
Employment Service
A. Pre-Employment
B. Employment Coaching
Individual Services Coordination
Transportation
HIV/AIDS Services
A. If HIV Neg, Pre-Exposure Prophylaxis
B. If HIV Neg, Post-Exposure Prophylaxis
C. If HIV Positive, HIV Treatment
Transitional Drug-Free Housing Services
Housing Support
Health Insurance Enrollment
Other Case Management Services
(Specify) ____________________________

Continuing Care
Relapse Prevention
Recovery Coaching
Self-Help and Mutual Support Groups
Spiritual Support
Other After Care Services
(Specify) ____________________________

Education Services

Screening
Brief Intervention
Brief Treatment
Referral to Treatment
Assessment
Treatment Planning
Recovery Planning
Individual Counseling
Group Counseling
Contingency Management
Community Reinforcement
Cognitive Behavioral Therapy
Family/Marriage Counseling
Co-Occurring Treatment Services
Pharmacological Interventions
HIV/AIDS Counseling
Cultural Interventions/Activities
Other Clinical Services
(Specify)_____________________________

1.
2.
3.
4.
5.
6.
7.

Substance Use Education
HIV/AIDS Education
Naloxone Training
Fentanyl Test Strip Training
Viral Hepatitis Education
Other STI Education Services
Other Education Services
(Specify) ____________________________

Recovery Support Services

1.
2.
3.
4.
5.

6.
7.
8.
9.

14

Peer Coaching or Mentoring
Vocational Services
Recovery Housing
Recovery Planning
Case Management Services to Specifically
Support Recovery
Alcohol- and Drug-Free Social Activities
Information and Referral
Other Recovery Support Services
(Specify)_________________________
Other Peer-to-Peer Recovery Support Services
(Specify) ____________________________

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.]
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

2.

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

15

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.”]
NOT ENROLLED
ENROLLED, FULL TIME
ENROLLED, PART TIME
REFUSED

2.

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

3.

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

16

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

17

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

2.

REFUSED

Currently Incarcerated

Are you currently awaiting charges, trial, or sentencing?
Yes
No
REFUSED

3.

Are you currently on parole or probation or intensive pretrial supervision?
Probation
Parole
Intensive Pretrial Supervision
No
REFUSED

4.

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

18

F.

MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY

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 IF THE CLIENT REPORTS THAT
THEY HAVE NOT EXPERIENCED THE CONDITION. SELECT REFUSED FOR NO RESPONSE]:
2a. Experienced serious depression

Days
|____|____|

2b. Experienced serious anxiety or tension

|____|____|

2c. Experienced hallucinations

|____|____|

2d. Experienced trouble understanding, concentrating, or
remembering

|____|____|

2e. Experienced trouble controlling violent behavior

|____|____|

2f. Attempted suicide
2g. Been prescribed medication for psychological/emotional
problem

|____|____|

REFUSED

|____|____|

[IF CLIENT REPORTS 1 OR MORE DAYS 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
NO REPORTED MENTAL HEALTH COMPLAINTS IN THE PAST 30 DAYS
REFUSED ____________________________________________________________________________

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 (SPECIFY) _____________________________

19

5.

Do you currently have medical/health insurance?
Yes
No
[GO TO NEXT SECTION]
REFUSED [GO TO NEXT SECTION]
5a. What type of insurance do you have [CHECK 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

20

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.
Yes
[IF YES] Specify How Many Times
No
REFUSED

2.

|____|____|

REFUSED

In the past 30 days, did you have interaction with family and/or friends that are supportive of your
recovery?
Yes
No
REFUSED

3.

How satisfied are you with your personal relationships?
Very Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Very Satisfied
REFUSED

4.

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

21

H. PROGRAM SPECIFIC QUESTIONS: 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.]
Client was reunited with child (or children)
1a. With Agency Supervision
1b. Without Agency Supervision
Client avoided out of home placement for child (or children)
None of the above

22

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.]
Private Health Insurance
Medicaid
Medicare
SSI/SSDI
TANF
SNAP
Other (SPECIFY)
NONE OF THE ABOVE
REFUSED

23

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?

1a. Enrolled in school
1b. Enrolled in vocational training
1c. Currently employed
1d. Living in stable housing

Yes
No
REFUSED
Yes
No
REFUSED
Yes
No
REFUSED
Yes
No
REFUSED

[IF YES], Do you believe that the services you received
from [INSERT GRANTEE NAME] helped you with this
achievement?
Yes
No
REFUSED
Yes
No
REFUSED
Yes
No
REFUSED
Yes
No
REFUSED

24

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:
1a. 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
1b. 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

25

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:
1a. 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
1b. 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

26

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.]
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 QUESTION 6.]

[QUESTIONS 2-5 SHOULD BE REPORTED BY GRANTEE STAFF ONLY AT INTAKE/BASELINE.]
2.

When the SBIRT was administered, how did the client screen?
Negative
Positive

3.

What was their screening score?
3a. Alcohol Use Disorders Identification Test (AUDIT)

=

|____|____|

3b. CAGE

=

|____|____|

3c. Drug Abuse Screening Test (DAST)

=

|____|____|

3d. DAST-10

=

|____|____|

3e. National Institute on Alcohol Abuse and Alcoholism (NIAAA) Guide

=

|____|____|

3f. Alcohol, Smoking and Substance Involvement Screening Test
(ASSIST)/Alcohol Subscore

=

|____|____|

3g. Other (SPECIFY)

=

|____|____|

______________________________________
______________________________________
______________________________________
4.

Were they willing to continue their participation in SBIRT services?
Yes
No

27

5.

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.]
5a. Brief Intervention
5b. Brief Treatment
5c. Referral to Treatment

Yes

No

[QUESTION 6 SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOW-UP AND
DISCHARGE.]
6.

Did the client receive the following types of services?
6a. Brief Intervention
6b. Brief Treatment
6c. Referral to Treatment

Yes

No

28

H7.

PROGRAM SPECIFIC QUESTIONS

[ALL H7 QUESTIONS 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
Not Permitted To Ask
REFUSED

[SKIP TO QUESTION 2]
[SKIP TO QUESTION 2]
[SKIP TO QUESTION 2]

Altogether, in the past 30 days, how many:

Response

1a. Sexual partners did you have?

Number:

REFUSED

|____|____|____|

1b. Did you engage in unprotected/condomless sex?
Yes
No → [SKIP TO QUESTION 2]

1c. Were any of your partners:

2.

1. Living with HIV and not taking HIV medications

Yes

No

2. A person who injects drugs
3. High on one or more substances

Yes
Yes

No
No

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

3.

Did the program provide access to the following?
3a1. An HIV test?
Yes
No
REFUSED

[SKIP TO QUESTION 3b1]
[SKIP TO QUESTION 3b1]

3a2. Was this the first time that you had been tested for HIV?
Yes
No
[SKIP TO QUESTION 3a5]
REFUSED [SKIP TO QUESTION 3a5]
3a3. Was HIV testing performed on-site or were you referred out for testing?
On-site
[SKIP TO QUESTION 3a5]
Referred out
REFUSED [SKIP TO QUESTION 3a5]

29

3a4. 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 (SPECIFY) _________________
3a5. What was the result?
Positive
Negative
[SKIP TO QUESTION 3a12]
Indeterminate
REFUSED [SKIP TO QUESTION 3b1]
3a6. Did you receive confirmatory testing?
Yes
No
REFUSED

[SKIP TO QUESTION 3a8]
[SKIP TO QUESTION 3a8]

3a7. What was the result?
Positive
Negative
Indeterminate
REFUSED
3a8. Were you connected to HIV treatment services within 30 days of the positive test result?
Yes
No
REFUSED

[SKIP TO QUESTION 3a10]
[SKIP TO QUESTION 3a10]

3a9. 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 (SPECIFY) _________________
3a10. Was rapid HIV testing offered to your substance-using and/or sexual partners?
Yes
No
[SKIP TO QUESTION 3b1]
REFUSED [SKIP TO QUESTION 3b1]

30

3a11. What was the number of drug-using and/or sexual partners offered HIV testing?
1
2
3
4 or more
REFUSED

[SKIP TO QUESTION 3b1]
[SKIP TO QUESTION 3b1]
[SKIP TO QUESTION 3b1]
[SKIP TO QUESTION 3b1]
[SKIP TO QUESTION 3b1]

3a12. 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
3b1. Did you receive a Rapid Hepatitis C (HCV) test?
Yes
No
REFUSED

[SKIP TO QUESTION 3c1]
[SKIP TO QUESTION 3c1]

3b2. Was this test followed up with confirmatory Hepatitis C (HCV RNA) testing?
Yes
No
3b3. What was the result of your HCV test?
Positive
Negative
[SKIP TO QUESTION 3c1]
Indeterminate
REFUSED [SKIP TO QUESTION 3c1]
3b4. Were you connected to Hepatitis C treatment services?
Yes
No
REFUSED
3c1. Did you receive a Hepatitis B (HBV) test?
Yes
No
REFUSED

[SKIP TO QUESTION 3d1]
[SKIP TO QUESTION 3d1]

3c2. What was the result of your HBV test?
Positive
Negative
[SKIP TO QUESTION 3d1]
Indeterminate
REFUSED [SKIP TO QUESTION 3d1]

31

3c3. Were you connected to Hepatitis B treatment services?
Yes
No
REFUSED
3d1. Was the client offered a Hepatitis A and B Vaccination?
Yes [GO TO SECTION I OR J/K]
No
REFUSED [GO TO SECTION I OR J/K]
3d2. Was the client referred out for vaccination?
Yes
No
REFUSED

32

H8.

PROGRAM SPECIFIC QUESTIONS [QUESTIONS 1, 2 AND 3 SHOULD BE ANSWERED BY THE
CLIENT AT FOLLOW-UP AND DISCHARGE]

1.

Is peer support available at this program?
Yes
No [SKIP TO QUESTION 3]

2.

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?
2a. Enrolled in school
2b. Enrolled in vocational training
2c. Currently employed
2d. Living in stable housing

3.

[IF YES], Do you believe that the services you
received from [INSERT GRANTEE NAME] helped
you with this achievement?
Yes
No
REFUSED
Yes
No
REFUSED
Yes
No
REFUSED
Yes
No
REFUSED

Yes
No
REFUSED
Yes
No
REFUSED
Yes
No
REFUSED
Yes
No
REFUSED

To what extent has this program improved your quality of life?
To a great extent
Somewhat
Very little
Not at all
REFUSED

33

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:
1a. 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
1b. 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
1c. 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
1d. 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

34

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?
Client screened positive
Client screened negative [SKIP TO QUESTION 2]
Client was not screened [SKIP TO QUESTION 2]
Client has a positive history
1a. Was the client referred to mental health services?
Yes [SKIP TO QUESTION 2 IF INTAKE/BASELINE; ANSWER 1b IF FOLLOW-UP/DISCHARGE]
No [SKIP TO QUESTION 2]
1b. 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]
2.

Did the client screen positive for, or have a history of, substance use disorder(s)?
Client screened positive
Client screened negative [SKIP TO QUESTION 3 IF FOLLOW-UP/DISCHARGE]
Client was not screened [SKIP TO QUESTION 3 IF FOLLOW-UP/DISCHARGE]
Client has a positive history
2a. Was the client referred to substance use disorder services?
Yes [ANSWER 2b IF FOLLOW-UP/DISCHARGE]
No [SKIP TO QUESTION 3 IF FOLLOW-UP/DISCHARGE]

[IF THIS IS AN INTAKE/BASELINE, SECTION H10 IS DONE.]
2b. Did the client receive substance use disorder services?
Yes
No

35

H10.

PROGRAM SPECIFIC QUESTIONS (continued)

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

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

36

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?
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.]

37

J.

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

1.

On what date was the client discharged?
|____|____| / |____|____| / |____|____|____|____|
MONTH
DAY
YEAR

2.

What is the client’s discharge status?
01 = Completion/Graduate [SKIP TO QUESTION 3]
02 = Termination
2a. 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) __________________________________

3.

Did the program order an HIV test for this client?
Yes
No

4.

[SKIP TO QUESTION 5]

Did the program refer this client for HIV testing with another provider?
Yes
No

5.

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

6.

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
38

K.

SERVICES RECEIVED UNDER GRANT FUNDING [REPORTED BY PROGRAM STAFF ONLY AT DISCHARGE.]

1. 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. YOU SHOULD HAVE AT LEAST ONE DAY
FOR MODALITY.]

Modality
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) ______________________

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 & Counseling
7. Transitional Drug-Free Housing Services
8. Housing Support
9. Health Insurance Enrollment
10. Other Case Management Services
(Specify) ___________________________

Days

|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|

Medical Services
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
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) ___________________________

Identify the number of SESSIONS provided to the client during the
client’s course of treatment/recovery. [ENTER ZERO IF NO SERVICES
PROVIDED. YOU SHOULD HAVE AT LEAST ONE SESSION IN ONE
SERVICE CATEGORY.]

Education Services
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) ___________________________

Treatment Services
Sessions
[SBIRT GRANTS: YOU MUST HAVE AT LEAST ONE SESSION FOR
ONE OF THE TREATMENT SERVICES NUMBERED 1 THROUGH 4.]

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Screening
Brief Intervention
Brief Treatment
Referral to Treatment
Assessment
Treatment Planning
Recovery Planning
Individual Counseling
Group Counseling
Contingency Management
Community Reinforcement
Cognitive Behavioral Therapy
Family/Marriage Counseling
Co-Occurring Treatment Services
Pharmacological Interventions
HIV/AIDS Counseling
Cultural Interventions/Activities
Other Clinical 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) _________________________
9. Other Peer-to-Peer Recovery Support
Services (Specify) ____________________

|___|___|___|

39

Sessions
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|

Sessions

|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|

Sessions

|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|

Sessions

|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|

Sessions

|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|
|___|___|___|

2.

Has this client attended 60% or more of their planned services?
Yes
No

3.

Did this client receive any services via telehealth or a virtual platform?
Yes
No

4.

Has this client previously been diagnosed with an opioid use disorder?
Yes
No [SKIP TO QUESTION 5]
4a. 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 a diagnosed opioid use disorder [SKIP TO QUESTION 5]
4b. Has this client taken the medication as prescribed?
Yes
No

5.

Has this client previously been diagnosed with an alcohol use disorder?
Yes
No [SKIP TO QUESTION 6]
5a. 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 [SKIP TO QUESTION 6]
5b. Has this client taken the medication as prescribed?
Yes
No

40

6.

Has this client previously been diagnosed with a stimulant use disorder?
Yes
No [SKIP TO QUESTION 7]
6a. In the past 30 days, which 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 for a stimulant use disorder [SKIP TO QUESTION 7]

|___|___|
|___|___|
|___|___|
|___|___|

6b. Has this client attended and participated in interventions for stimulant use disorder?
Yes
No
7.

Has this client previously been diagnosed with a tobacco use disorder?
Yes
No [THE DISCHARGE INTERVIEW IS COMPLETE.]
7a. 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 [THE DISCHARGE
INTERVIEW IS COMPLETE.]
7b. Has this client taken the medication as prescribed?
Yes
No

[THE DISCHARGE INTERVIEW IS COMPLETE.]

41