Form SUPRT-Client
SAMHSA Unified Performance Reporting Tool (SUPRT)
SUPRT - Client
SUPRT-Client
OMB: 0930-0400
S
AMHSA
Unified Performance Reporting Tool (SUPRT) - C
OMB 0930-NEW EXPIRES: MM/DD/YYYY
Substance Abuse and Mental Health Services Administration (SAMHSA) Unified Performance Reporting Tool (SUPRT) - C
CLIENT OR CAREGIVER FORM
Version: September 2024
Age Range |
Respondent Type |
Assessment |
Link |
Adult (18 years+) |
Client (or proxy) |
Baseline |
|
Adult (18 years+) |
Client (or proxy) |
Reassessment |
|
Adult (18 years+) |
Client (or proxy) |
Annual |
|
Youth (12-17 years) |
Client (or proxy) |
Baseline |
|
Youth (12-17 years) |
Client (or proxy) |
Reassessment |
|
Child (5-17 years) |
Caregiver/Parent |
Baseline |
|
Child (5-17 years) |
Caregiver/Parent |
Reassessment |
|
Young Child (0-4 years) |
Caregiver/Parent |
Baseline |
|
Young Child (0-4 years) |
Caregiver/Parent |
Reassessment |
SUPRT-C FORM VERSION: Adult / Client / Baseline
CLIENT CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for Adults (persons 18 years or older) responding for themselves. If that’s not you, please ask your provider for the form for Caregivers/Family Members or for youth (12-17 years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your provider.
How is my information used?
SAMHSA does not collect your name or information that can identify you. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data. SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
skip questions you do not want to answer.
stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 15 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.
DEMOGRAPHICS
What is your race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group
White – Provide details below.
German
Irish
English
Italian
Polish
French
Enter, for example, Scottish, Norwegian, Dutch, etc. ____________
Hispanic or Latino – Provide details below.
Mexican or Mexican American
Puerto Rican
Cuban
Salvadoran
Dominican
Colombian
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc.________
Black or African American – Provide details below.
African American
Jamaican
Haitian
Nigerian
Ethiopian
Somali
Enter, for example, Ghanaian, South African, Barbadian, etc.______
Asian – Provide details below.
Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Enter, for example, Pakistani, Cambodian, Hmong, etc. ________
American Indian or Alaska Native – Provide details below.
Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Tlingit, etc. ___________
Middle Eastern or North African – Provide details below.
Lebanese
Iranian
Egyptian
Syrian
Moroccan
Israeli
Enter, for example, Algerian, Iraqi, Kurdish, etc. ___________
Native Hawaiian or Pacific Islander – Provide details below.
Native Hawaiian
Samoan
Chamorro
Tongan
Fijian
Marshallese
Enter, for example, Palauan, Tahitian, Chuukese etc. ____________
What is your gender?
Female
Male
I don’t know
Two-Spirit [If you are American Indian or Alaska Native]
I use a different term – specify: _______
Prefer not to answer
What was your sex assigned at birth, for example on your original birth certificate?
Female
Male
I don’t know
Prefer not to answer
Which of the following best represents how you think of yourself?
Lesbian or gay
Straight or Heterosexual
Bisexual
Two-Spirit [If you are American Indian or Alaska Native]
I use a different term – specify: _______
I don’t know
Prefer not to answer
Do you speak a language other than English at home? (If no, please skip to question 6)
Yes
No
Prefer not to answer
5a. For persons speaking a language other than English (answering yes to the question above): What is this language(s)? (Check all that apply)
American Sign Language (ASL)
Arabic
Chinese
French
Portuguese
Spanish
Other Language (Identify): _______
Prefer not to answer
Have you ever served in the Armed Forces, the Reserves, the National Guard or other Uniformed Services?
Yes, currently serving
Yes, served in the past
No
Prefer not to answer
Please respond to the following questions about your physical health.
|
Yes |
No |
Prefer not to answer |
a. Are you deaf or do you have serious difficulty hearing? |
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|
|
b. Are you blind or do you have serious difficulty seeing, even when wearing glasses? |
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|
|
c. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? |
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|
d. Do you have serious difficulty walking or climbing stairs? |
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|
e. Do you have difficulty dressing or bathing? |
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|
f. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? |
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|
SOCIAL DRIVERS OF HEALTH
How hard is it for you to pay for the very basics like food, housing, medical care, and heating?
Very hard
Somewhat hard
Not hard at all
Prefer not to answer
What is your living situation today?
I have a steady place to live
I have a place to live today but I am worried about losing it in the future
I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)
Prefer not to answer
Which of the following best describes your current living situation?
House or apartment
Your partner’s place
A friend or relative’s and paying rent
A friend or relative’s and not paying rent
Permanent housing program
Transitional housing program
Domestic violence shelter
Emergency shelter
Voucher hotel or motel
Hotel or motel you pay for
Residential drug or alcohol program
Jail or prison
Car or other vehicle
Abandoned building
Anywhere outside
Somewhere else [where]: ________
Prefer not to answer
Are you currently employed?
Employed, full time or part time (includes temporary, seasonal, hours change each week)
Not employed, seeking employment
Not employed, not seeking employment (includes if you are in school and not seeking a job, retired, not looking for work because of a disability, a homemaker, etc.)
Other – specify: ______________
Prefer not to answer
What is the highest level of education you have finished?
Less than high school diploma
High school degree or GED
Some vocational, technical or college, university
Associate's degree
4-year degree or higher
Prefer not to answer
In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?
Enrolled, attending regularly
Enrolled, not attending regularly
Not enrolled
Prefer not to answer
In the last 3 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply.
Yes, it has kept me from medical appointments or from getting my medications.
Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
No
Prefer not to answer
CLIENT-REPORTED CORE OUTCOMES
Please choose the option that best applies to you right now:
I consider myself to be in recovery from substance use issues
I consider myself to be in recovery from mental health issues
I consider myself to be in recovery from substance use and mental health issues
I do not consider myself to be in recovery for substance use or mental health issues
I Prefer not to answer
As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below.
Strongly Agree
Agree
Somewhat Agree
Somewhat Disagree
Disagree
Strongly Disagree
Prefer not to answer
a. I am physically fine most days.
b. My mental health is fine most days.
c. My substance use does not cause problems in my life.
d. I have stable housing.
e. I have a steady job or am involved in things like school, training, or volunteering.
f. My life has purpose and meaning.
g. I have enough money to meet my needs.
h. I am proud of the community I live in and feel a part of it.
i. I am supported by the people around me.
j. The future appears bright to me.
k. I am in control of my life.
l. I bounce back quickly after hard times.
On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life? ______
Which goals do you have for participating in this program? Check all that apply.
Improve the symptoms that led me to services (for example distress, anxiety)
Reduce my drug and/or alcohol use
Gain access to medical services I need
Enroll in or finish education (for example GED, degree, vocational training)
Get or maintain a job
Live in stable housing
Be a better parent or caregiver
Improve my friendships and relationships
Comply with court order or avoid contact with the police and/or justice system
Other goal - Please describe: ________________
Prefer not to answer
Thank you for completing this baseline form.
Public reporting burden for this collection of information is estimated to average 15 minutes per response . 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-NEW.
[OFFICE USE ONLY] RECORD MANAGEMENT – ADULT / CLIENT / BASELINE
Client ID |____|____|____|____|____|____|____|____|____|____|____|
Site ID |__|__|__|__|__|__|__|__|__|__|__| Grant ID |__|__|__|__|__|__|__|__|
1. Was this assessment conducted with the client/caregiver? O Yes – Client O Yes – Caregiver/Proxy O No
1a. [IF QUESTION 1 IS YES] When (MM/DD/YYYY)? |__|__/__|__/__|__|__|__|
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
O Client/Caregiver was unable to provide consent O Client was not reached for assessment O Client no longer in care
SUPRT-C FORM VERSION: Adult / Client / Reassessment
CLIENT CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for Adults (persons 18 years or older) responding for themselves. If that’s not you, please ask your provider for the form for Caregivers/Family Members or for youth (12-17 years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your provider.
How is my information used?
SAMHSA does not collect your name or information that can identify you. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data. SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
skip questions you do not want to answer.
stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 10 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.
SOCIAL DRIVERS OF HEALTH
How hard is it for you to pay for the very basics like food, housing, medical care, and heating?
Very hard
Somewhat hard
Not hard at all
Prefer not to answer
What is your living situation today?
I have a steady place to live
I have a place to live today but I am worried about losing it in the future
I do not have a steady place to live
Prefer not to answer
Which of the following best describes your current living situation?
House or apartment
Your partner’s place
A friend or relative’s and paying rent
A friend or relative’s and not paying rent
Permanent housing program
Transitional housing program
Domestic violence shelter
Emergency shelter
Voucher hotel or motel
Hotel or motel you pay for
Residential drug or alcohol program
Jail or prison
Car or other vehicle
Abandoned building
Anywhere outside
Somewhere else [where]: _______
Prefer not to answer
Are you currently employed?
Employed, full time or part time (includes temporary, seasonal, hours change each week)
Not employed, seeking employment
Not employed, not seeking employment (includes in school not seeking, retired, due to disability, homemaker, etc)
Other – specify: ______________
Prefer not to answer
What is the highest level of education you have finished?
Less than high school diploma
High school degree or GED
Some vocational, technical or college, university
Associate's degree
4-year degree or higher
Prefer not to answer
In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?
Enrolled, attending regularly
Enrolled, not attending regularly
Not enrolled
Prefer not to answer
In the last 3 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply.
Yes, it has kept me from medical appointments or from getting my medications.
Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
No
Prefer not to answer
B. CLIENT-REPORTED CORE OUTCOMES
Please choose the option that best applies to you right now:
I consider myself to be in recovery from substance use issues
I consider myself to be in recovery from mental health issues
I consider myself to be in recovery from substance use and mental health issues
I do not consider myself to be in recovery for substance use or mental health issues
I Prefer not to answer
As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below.
|
Strongly Agree |
Agree |
Somewhat Agree |
Somewhat Disagree |
Disagree |
Strongly Disagree |
Prefer not to answer |
a. I am physically fine most days. |
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b. My mental health is fine most days. |
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c. My substance use does not cause problems in my life. |
|
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|
|
|
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d. I have stable housing. |
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|
|
|
|
|
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e. I have a steady job or am involved in things like school, training, or volunteering. |
|
|
|
|
|
|
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f. My life has purpose and meaning. |
|
|
|
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g. I have enough money to meet my needs. |
|
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|
|
|
|
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h. I am proud of the community I live in and feel a part of it. |
|
|
|
|
|
|
|
i. I am supported by the people around me. |
|
|
|
|
|
|
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j. The future appears bright to me. |
|
|
|
|
|
|
|
k. I am in control of my life. |
|
|
|
|
|
|
|
l. I bounce back quickly after hard times. |
|
|
|
|
|
|
|
On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life? ______
As a result of the services you received, which goals did you make progress on? Check all that apply.
Improve the symptoms that led me to services (for example distress, anxiety)
Reduce my drug and/or alcohol use
Gain access to medical services I need
Enroll in or finish education (for example GED, degree, vocational training)
Get or maintain a job
Live in stable housing
Be a better parent or caregiver
Improve my friendships and relationships
Comply with court order or avoid contact with the police and/or justice system
Other goal - Please describe: ________________
Prefer not to answer
Thank you for completing this reassessment form.
Public reporting burden for this collection of information is estimated to average 10 minutes per response. 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-NEW.
[OFFICE USE ONLY] RECORD MANAGEMENT – ADULT / CLIENT / REASSESSMENT
Client ID |____|____|____|____|____|____|____|____|____|____|____|
Site ID |__|__|__|__|__|__|__|__|__|__|__| Grant ID |__|__|__|__|__|__|__|__|
1. Was this assessment conducted with the client/caregiver? O Yes – Client O Yes – Caregiver/Proxy O No
1a. [IF QUESTION 1 IS YES] When (MM/DD/YYYY)? |__|__/__|__/__|__|__|__|
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
O Client/Caregiver was unable to provide consent O Client was not reached for assessment O Client no longer in care
SUPRT-C FORM VERSION: Adult / Client / Annual
CLIENT CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for Adults (persons 18 years or older) responding for themselves. If that’s not you, please ask your provider for the form for Caregivers/Family Members or for youth (12-17 years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your provider.
How is my information used?
SAMHSA does not collect your name or information that can identify you. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data. SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
skip questions you do not want to answer.
stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 7 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.
A. CLIENT-REPORTED CORE OUTCOMES
Please choose the option that best applies to you right now:
I consider myself to be in recovery from substance use issues
I consider myself to be in recovery from mental health issues
I consider myself to be in recovery from substance use and mental health issues
I do not consider myself to be in recovery for substance use or mental health issues
I Prefer not to answer
As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below.
|
Strongly Agree |
Agree |
Somewhat Agree |
Somewhat Disagree |
Disagree |
Strongly Disagree |
Prefer not to answer |
a. I am physically fine most days. |
|
|
|
|
|
|
|
b. My mental health is fine most days. |
|
|
|
|
|
|
|
c. My substance use does not cause problems in my life. |
|
|
|
|
|
|
|
d. I have stable housing. |
|
|
|
|
|
|
|
e. I have a steady job or am involved in things like school, training, or volunteering. |
|
|
|
|
|
|
|
f. My life has purpose and meaning. |
|
|
|
|
|
|
|
g. I have enough money to meet my needs. |
|
|
|
|
|
|
|
h. I am proud of the community I live in and feel a part of it. |
|
|
|
|
|
|
|
i. I am supported by the people around me. |
|
|
|
|
|
|
|
j. The future appears bright to me. |
|
|
|
|
|
|
|
k. I am in control of my life. |
|
|
|
|
|
|
|
l. I bounce back quickly after hard times. |
|
|
|
|
|
|
|
On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life? ______
____________________________________________________________________________________
As a result of the services you received, which goals did you make progress on? Check all that apply.
Improve the symptoms that led me to services (for example distress, anxiety)
Reduce my drug and/or alcohol use
Gain access to medical services I need
Enroll in or finish education (for example GED, degree, vocational training)
Get or maintain a job
Live in stable housing
Be a better parent or caregiver
Improve my friendships and relationships
Comply with court order or avoid contact with the police and/or justice system
Other goal - Please describe: ________________
Prefer not to answer
Thank you for completing this annual assessment form.
Public reporting burden for this collection of information is estimated to average 7 minutes per response. 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-NEW.
[OFFICE USE ONLY] RECORD MANAGEMENT – ADULT / CLIENT / ANNUAL
Client ID |____|____|____|____|____|____|____|____|____|____|____|
Site ID |__|__|__|__|__|__|__|__|__|__|__| Grant ID |__|__|__|__|__|__|__|__|
1. Was this assessment conducted with the client/caregiver? O Yes – Client O Yes – Caregiver/Proxy O No
1a. [IF QUESTION 1 IS YES] When (MM/DD/YYYY)? |__|__/__|__/__|__|__|__|
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
O Client/Caregiver was unable to provide consent O Client was not reached for assessment O Client no longer in care
SUPRT-C FORM VERSION: Youth (12 to 17) / Client / Baseline
CLIENT CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for Youth (persons 12 to 17 years old) responding for themselves. If that’s not you, please ask your provider for the form for Caregivers/Family Members or for Adults (18+ years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your provider.
How is my information used?
SAMHSA does not collect your name or information that can identify you. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data. SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
skip questions you do not want to answer.
stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 10 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.
DEMOGRAPHICS
What is your race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group
White – Provide details below.
German
Irish
English
Italian
Polish
French
Enter, for example, Scottish, Norwegian, Dutch, etc. ____________
Hispanic or Latino – Provide details below.
Mexican or Mexican American
Puerto Rican
Cuban
Salvadoran
Dominican
Colombian
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc.________
Black or African American – Provide details below.
African American
Jamaican
Haitian
Nigerian
Ethiopian
Somali
Enter, for example, Ghanaian, South African, Barbadian, etc.______
Asian – Provide details below.
Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Enter, for example, Pakistani, Cambodian, Hmong, etc. ________
American Indian or Alaska Native – Provide details below.
Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Tlingit, etc. ___________
Middle Eastern or North African – Provide details below.
Lebanese
Iranian
Egyptian
Syrian
Moroccan
Israeli
Enter, for example, Algerian, Iraqi, Kurdish, etc. ___________
Native Hawaiian or Pacific Islander – Provide details below.
Native Hawaiian
Samoan
Chamorro
Tongan
Fijian
Marshallese
Enter, for example, Palauan, Tahitian, Chuukese etc. ____________
What is your gender?
Female
Male
I don’t know
Two-Spirit [If you are American Indian or Alaska Native]
I use a different term – specify: _______
Prefer not to answer
What was your sex assigned at birth, for example on your original birth certificate?
Female
Male
I don’t know
Prefer not to answer
Which of the following best represents how you think of yourself?
Lesbian or gay
Straight or Heterosexual
Bisexual
Two-Spirit [If you are American Indian or Alaska Native]
I use a different term – specify: _______
I don’t know
Prefer not to answer
Do you speak a language other than English at home? (If no, please skip to question 6)
Yes
No
Prefer not to answer
5a. For persons speaking a language other than English (answering yes to the question above): What is this language(s)? (Check all that apply)
American Sign Language (ASL)
Arabic
Chinese
French
Portuguese
Spanish
Other Language (Identify): _______
Prefer not to answer
Have you ever served in the Armed Forces, the Reserves, the National Guard or other Uniformed Services?
Yes, currently serving
Yes, served in the past
No
Prefer not to answer
Please respond to the following questions about your physical health.
|
Yes |
No |
Prefer not to answer |
a. Are you deaf or do you have serious difficulty hearing? |
|
|
|
b. Are you blind or do you have serious difficulty seeing, even when wearing glasses? |
|
|
|
c. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? |
|
|
|
d. Do you have serious difficulty walking or climbing stairs? |
|
|
|
e. Do you have difficulty dressing or bathing? |
|
|
|
f. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? |
|
|
|
SOCIAL DRIVERS OF HEALTH
What is your living situation today?
I have a steady place to live
I have a place to live today but I am worried about losing it in the future
I do not have a steady place to live
Prefer not to answer
Which of the following best describes your current living situation?
My parent/gaurdian’s house or apartment;
Your partner’s place;
A friend or relative’s and paying rent;
A friend or relative’s and not paying rent;
Permanent housing program;
Transitional housing program;
Domestic violence shelter;
Emergency shelter;
Voucher hotel or motel;
Hotel or motel you pay for;
Residential drug or alcohol program;
Jail or prison;
Car or other vehicle;
Abandoned building;
Anywhere outside;
Somewhere else [where]: _______
Prefer not to answer
What is the highest level of education you have finished?
Preschool-Kindergarten
Grade 1 – Grade 5
Grade 6 – Grade 8
Grade 9 – 12
High school degree or GED
Prefer not to answer
In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?
Enrolled, attending regularly
Enrolled, not attending regularly
Not enrolled
Prefer not to answer
Thank you for completing this baseline form.
Public reporting burden for this collection of information is estimated to average 10 minutes per response. 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-NEW.
[OFFICE USE ONLY] RECORD MANAGEMENT – YOUTH / CLIENT / BASELINE
Client ID |____|____|____|____|____|____|____|____|____|____|____|
Site ID |__|__|__|__|__|__|__|__|__|__|__| Grant ID |__|__|__|__|__|__|__|__|
1. Was this assessment conducted with the client/caregiver? O Yes – Client O Yes – Caregiver/Proxy O No
1a. [IF QUESTION 1 IS YES] When (MM/DD/YYYY)? |__|__/__|__/__|__|__|__|
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
O Client/Caregiver was unable to provide consent O Client was not reached for assessment O Client no longer in care
SUPRT-C FORM VERSION: Youth (12 to 17) / Client / Reassessment
CLIENT CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for Youth (persons 12 to 17 years old) responding for themselves. If that’s not you, please ask your provider for the form for Caregivers/Family Members or for Adults (18+ years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your provider.
How is my information used?
SAMHSA does not collect your name or information that can identify you. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data. SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
skip questions you do not want to answer.
stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 5 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.
A. SOCIAL DRIVERS OF HEALTH
What is your living situation today?
I have a steady place to live
I have a place to live today but I am worried about losing it in the future
I do not have a steady place to live
Prefer not to answer
Which of the following best describes your current living situation?
My parent/gaurdian’s house or apartment
Your partner’s place
A friend or relative’s and paying rent
A friend or relative’s and not paying rent
Permanent housing program
Transitional housing program
Domestic violence shelter
Emergency shelter
Voucher hotel or motel
Hotel or motel you pay for
Residential drug or alcohol program
Jail or prison
Car or other vehicle
Abandoned building
Anywhere outside
Somewhere else [where]: _______
Prefer not to answer
What is the highest level of education you have finished?
Preschool-Kindergarten
Grade 1 – Grade 5
Grade 6 – Grade 8
Grade 9 - 12
High school degree or GED
Prefer not to answer
In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?
Enrolled, attending regularly
Enrolled, not attending regularly
Not enrolled
Prefer not to answer
Thank you for completing this reassessment form.
Public reporting burden for this collection of information is estimated to average 5 minutes per response. 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-NEW.
[OFFICE USE ONLY] RECORD MANAGEMENT – YOUTH / CLIENT / REASSESSMENT
Client ID |____|____|____|____|____|____|____|____|____|____|____|
Site ID |__|__|__|__|__|__|__|__|__|__|__| Grant ID |__|__|__|__|__|__|__|__|
1. Was this assessment conducted with the client/caregiver? O Yes – Client O Yes – Caregiver/Proxy O No
1a. [IF QUESTION 1 IS YES] When (MM/DD/YYYY)? |__|__/__|__/__|__|__|__|
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
O Client/Caregiver was unable to provide consent O Client was not reached for assessment O Client no longer in care
SUPRT-C FORM VERSION: Child (5 to 17) / Caregiver / Baseline
CAREGIVER/FAMILY MEMBER CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for caregivers or family members responding for their child. If that’s not you, please ask your provider for the form for Youth (12 to 17) responding for themselves or for Adults (18+ years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your child’s behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your child’s provider.
How is my information used?
SAMHSA does not collect your child’s name or information that can identify your child. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data. SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
skip questions you do not want to answer.
stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 10 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.
DEMOGRAPHICS
What is your child’s race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.
White – Provide details below.
German
Irish
English
Italian
Polish
French
Enter, for example, Scottish, Norwegian, Dutch, etc. ____________
Hispanic or Latino – Provide details below.
Mexican or Mexican American
Puerto Rican
Cuban
Salvadoran
Dominican
Colombian
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc.________
Black or African American – Provide details below.
African American
Jamaican
Haitian
Nigerian
Ethiopian
Somali
Enter, for example, Ghanaian, South African, Barbadian, etc.______
Asian – Provide details below.
Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Enter, for example, Pakistani, Cambodian, Hmong, etc. ________
American Indian or Alaska Native – Provide details below.
Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Tlingit, etc. ___________
Middle Eastern or North African – Provide details below.
Lebanese
Iranian
Egyptian
Syrian
Moroccan
Israeli
Enter, for example, Algerian, Iraqi, Kurdish, etc. ___________
Native Hawaiian or Pacific Islander – Provide details below.
Native Hawaiian
Samoan
Chamorro
Tongan
Fijian
Marshallese
Enter, for example, Palauan, Tahitian, Chuukese etc. ____________
What was your child’s sex assigned at birth, for example on their original birth certificate?
Female
Male
I don’t know
Prefer not to answer
Does your child speak a language other than English at home?
Yes
No
Prefer not to answer
3a. For persons speaking a language other than English (answering yes to the questionabove): What is this language(s)? (Check all that apply)
American Sign Language (ASL)
Arabic
Chinese
French
Portuguese
Spanish
Other Language (specify): ____
Prefer not to answer
Please respond to the following questions about your child’s physical health.
|
Yes |
No |
Prefer not to answer |
a. Is your child deaf or does your child have serious difficulty hearing? |
|
|
|
b. Is your child blind or does your child have serious difficulty seeing, even when wearing glasses? |
|
|
|
c. Because of a physical, mental, or emotional condition, does your child have serious difficulty concentrating, remembering, or making decisions? |
|
|
|
d. Does your child have serious difficulty walking or climbing stairs? |
|
|
|
e. Does your child have difficulty dressing or bathing? |
|
|
|
f. Because of a physical, mental, or emotional condition, does your child have difficulty doing errands alone such as visiting a doctor’s office or shopping? |
|
|
|
SOCIAL-DRIVERS OF HEALTH
How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?
Very hard
Somewhat hard
Not hard at all
I am not the person responsible for paying for the basics for my child
Prefer not to answer
What is your child’s living situation today?
My child has a steady place to live
My child has a place to live today but I am worried they may lose it in the future
My child does not have a steady place to live
Prefer not to answer
Which of the following best describes your child’s current living situation?
My parent/gaurdian’s house or apartment
Your partner’s place
A friend or relative’s and paying rent
A friend or relative’s and not paying rent
Permanent housing program
Transitional housing program
Domestic violence shelter
Emergency shelter
Voucher hotel or motel
Hotel or motel you pay for
Residential drug or alcohol program
Jail or prison
Car or other vehicle
Abandoned building
Anywhere outside
Somewhere else [where]: _______
Prefer not to answer
What is the highest level of education your child has finished?
Preschool-Kindergarten
Grade 1 – Grade 5
Grade 6 – Grade 8
Grade 9 - 12
High school degree or GED
Prefer not to answer
In the last 3 months, has your child attended school/college, homeschool, or vocational training regularly?
Enrolled, attending regularly
Enrolled, not attending regularly
Not enrolled
Prefer not to answer
Thank you for completing this baseline form.
Public reporting burden for this collection of information is estimated to average 10 minutes per response at baseline. 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-NEW.
[OFFICE USE ONLY] RECORD MANAGEMENT – CHILD / CAREGIVER / BASELINE
Client ID |____|____|____|____|____|____|____|____|____|____|____|
Site ID |__|__|__|__|__|__|__|__|__|__|__| Grant ID |__|__|__|__|__|__|__|__|
1. Was this assessment conducted with the client/caregiver? O Yes – Client O Yes – Caregiver/Proxy O No
1a. [IF QUESTION 1 IS YES] When (MM/DD/YYYY)? |__|__/__|__/__|__|__|__|
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
O Client/Caregiver was unable to provide consent O Client was not reached for assessment O Client no longer in care
FORM VERSION: Child (5 to 17) / Caregiver / Reassessment
CAREGIVER/FAMILY MEMBER CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for caregivers or family members responding for their child. If that’s not you, please ask your provider for the form for Youth (12 to 17) responding for themselves or for Adults (18+ years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your child’s behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your child’s provider.
How is my information used?
SAMHSA does not collect your child’s name or information that can identify your child. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data. SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
skip questions you do not want to answer.
stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 5 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.
A. SOCIAL DRIVERS OF HEALTH
How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?
Very hard
Somewhat hard
Not hard at all
I am not the person responsible for paying for the basics for my child
Prefer not to answer
What is your child’s living situation today?
My child has a steady place to live
My child has a place to live today but I am worried they may lose it in the future
My child does not have a steady place to live
Prefer not to answer
Which of the following best describes your child’s current living situation?
Your house or apartment
Your partner’s place
A friend or relative’s and paying rent
A friend or relative’s and not paying rent
Permanent housing program
Transitional housing program
Domestic violence shelter
Emergency shelter
Voucher hotel or motel
Hotel or motel you pay for
Residential drug or alcohol program
Jail or prison
Car or other vehicle
Abandoned building
Anywhere outside
Somewhere else [where]: _______
Prefer not to answer
What is the highest level of education your child has finished?
Preschool-Kindergarten
Grade 1 – Grade 5
Grade 6 – Grade 8
Grade 9 - 12
High school degree or GED
Prefer not to answer
In the last 3 months, has your child attended school/college, homeschool, or vocational training regularly?
Enrolled, attending regularly
Enrolled, not attending regularly
Not enrolled
Prefer not to answer
Thank you for completing this reassessment form.
Public reporting burden for this collection of information is estimated to average 10 minutes per response. 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-NEW.
[OFFICE USE ONLY] RECORD MANAGEMENT – CHILD / CAREGIVER / BASELINE
Client ID |____|____|____|____|____|____|____|____|____|____|____|
Site ID |__|__|__|__|__|__|__|__|__|__|__| Grant ID |__|__|__|__|__|__|__|__|
1. Was this assessment conducted with the client/caregiver? O Yes – Client O Yes – Caregiver/Proxy O No
1a. [IF QUESTION 1 IS YES] When (MM/DD/YYYY)? |__|__/__|__/__|__|__|__|
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
O Client/Caregiver was unable to provide consent O Client was not reached for assessment O Client no longer in care
SUPRT-C FORM VERSION: Young Child (0 to4) / Caregiver / Baseline
CAREGIVER/FAMILY MEMBER CONSENT
Are you answering for your child (aged 0 to 4) as a caregiver or family member? This form was designed for caregivers or family members responding for their young child. If that’s not you, please ask your provider for the form for a Child (5 to 17) or Youth (12 to 17) responding for themselves.
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your child’s behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your child’s provider.
How is my information used?
SAMHSA does not collect your child’s name or information that can identify your child. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data. SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
skip questions you do not want to answer.
stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 6 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.
DEMOGRAPHICS
What is your child’s race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.
White – Provide details below.
German
Irish
English
Italian
Polish
French
Enter, for example, Scottish, Norwegian, Dutch, etc. ________
Hispanic or Latino – Provide details below.
Mexican or Mexican American
Puerto Rican
Cuban
Salvadoran
Dominican
Colombian
Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc.____
Black or African American – Provide details below.
African American
Jamaican
Haitian
Nigerian
Ethiopian
Somali
Enter, for example, Ghanaian, South African, Barbadian, etc. ___
Asian – Provide details below.
Chinese
Filipino
Asian Indian
Vietnamese
Korean
Japanese
Enter, for example, Pakistani, Cambodian, Hmong, etc. _____
American Indian or Alaska Native
Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Tlingit, etc. ___________
Middle Eastern or North African – Provide details below.
Lebanese
Iranian
Egyptian
Syrian
Moroccan
Israeli
Enter, for example, Algerian, Iraqi, Kurdish, etc. ___________
Native Hawaiian or Pacific Islander – Provide details below.
Native Hawaiian
Samoan
Chamorro
Tongan
Fijian
Marshallese
Enter, for example, Palauan, Tahitian, Chuukese etc. _________
What was your child’s sex assigned at birth, for example on their original birth certificate?
Female
Male
I don’t know
Prefer not to answer
Please respond to the following questions about your child’s physical health.
|
Yes |
No |
Prefer not to answer |
a. Is your child deaf or does your child have serious difficulty hearing? |
|
|
|
b. Is your child blind or does your child have serious difficulty seeing, even when wearing glasses? |
|
|
|
SOCIAL DRIVERS OF HEALTH
How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?
Very hard
Somewhat hard
Not hard at all
I am not the person responsible for paying for the basics for my child
Prefer not to answer
What is your child’s living situation today?
My child has a steady place to live
My child has a place to live today but I am worried they may lose it in the future
My child does not have a steady place to live
Prefer not to answer
Which of the following best describes your child’s current living situation?
Their parent/gaurdian’s house or apartment
Your partner’s place
A friend or relative’s and paying rent
A friend or relative’s and not paying rent
Permanent housing program
Transitional housing program
Domestic violence shelter
Emergency shelter
Voucher hotel or motel
Hotel or motel you pay for
Residential drug or alcohol program
Jail or prison
Car or other vehicle
Abandoned building
Anywhere outside
Somewhere else [where]: _______
Prefer not to answer
Thank you for completing this baseline form.
Public reporting burden for this collection of information is estimated to average 6 minutes per response . 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-NEW.
[OFFICE USE ONLY] RECORD MANAGEMENT – YOUNG CHILD / CAREGIVER / BASELINE
Client ID |____|____|____|____|____|____|____|____|____|____|____|
Site ID |__|__|__|__|__|__|__|__|__|__|__| Grant ID |__|__|__|__|__|__|__|__|
1. Was this assessment conducted with the client/caregiver? O Yes – Client O Yes – Caregiver/Proxy O No
1a. [IF QUESTION 1 IS YES] When (MM/DD/YYYY)? |__|__/__|__/__|__|__|__|
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
O Client/Caregiver was unable to provide consent O Client was not reached for assessment O Client no longer in care
FORM VERSION: Young Child (0 to 4) / Caregiver / Reassessment
CAREGIVER/FAMILY MEMBER CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for caregivers or family members responding for their young child. If that’s not you, please ask your provider for the form for Child (5 to 17) or Youth (12 to 17) responding for themselves.
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your child’s behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your child’s provider.
How is my information used?
SAMHSA does not collect your child’s name or information that can identify your child. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data. SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
skip questions you do not want to answer.
stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 3 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.
A. SOCIAL DRIVERS OF HEALTH
How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?
Very hard
Somewhat hard
Not hard at all
I am not the person responsible for paying for the basics for my child
Prefer not to answer
What is your child’s living situation today?
My child has a steady place to live
My child has a place to live today but I am worried they may lose it in the future
My child does not have a steady place to live
Prefer not to answer
Which of the following best describes your child’s current living situation?
Their parent/gaurdian’s house or apartment
Your partner’s place
A friend or relative’s and paying rent
A friend or relative’s and not paying rent
Permanent housing program
Transitional housing program
Domestic violence shelter
Emergency shelter
Voucher hotel or motel
Hotel or motel you pay for
Residential drug or alcohol program
Jail or prison
Car or other vehicle
Abandoned building
Anywhere outside
Somewhere else [where]: _______
Prefer not to answer
Thank you for completing this reassessment form.
Public reporting burden for this collection of information is estimated to average 3 minutes per response. 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-NEW.
[OFFICE USE ONLY] RECORD MANAGEMENT – YOUNG CHILD / CAREGIVER / REASSESSMENT
Client ID |____|____|____|____|____|____|____|____|____|____|____|
Site ID |__|__|__|__|__|__|__|__|__|__|__| Grant ID |__|__|__|__|__|__|__|__|
1. Was this assessment conducted with the client/caregiver? O Yes – Client O Yes – Caregiver/Proxy O No
1a. [IF QUESTION 1 IS YES] When (MM/DD/YYYY)? |__|__/__|__/__|__|__|__|
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
O Client/Caregiver was unable to provide consent O Client was not reached for assessment O Client no longer in care
Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | CMHS NOMs Client-Level Services Tool for Adults |
| Subject | CMHS NOMs Client-Level Services Tool for Adults revised March 2019 |
| Author | Substance Abuse and Mental Health Services Administration |
| File Modified | 0000-00-00 |
| File Created | 2024-12-08 |
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