SUPRT-Administrati SUPRT-Administrative
SAMHSA Unified Performance Reporting Tool (SUPRT)
SUPRT - Administrative
OMB: 0930-0400
S
AMHSA
Unified Performance Reporting Tool (SUPRT) - A (Administrative
Report)
OMB 0930-NEW EXPIRES: MM/DD/YYYY
Substance Abuse and Mental Health Services Administration (SAMHSA)
Unified Performance Reporting Tool (SUPRT) - A
ADMINISTRATIVE REPORT
Version: August 2024
Public reporting burden for this collection of information is estimated to average 20 minutes per response if all applicable sections are completed. To the extent that providers are able to incorporate and obtain much of this information as part of their ongoing client/consumer/participant intake, client record keeping, or follow-up, less time will be required for collection from clients specifically for this collection. 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.
Table of Contents
Client ID |__|__|__|__|__|__|__|__|__|__|__|
Site ID |__|__|__|__|__|__|__|__|__|__|
Grant ID |__|__|__|__|__|__|__|__|
[AT BASELINE] What is the client’s month and year of birth (MM/YYYY)?
|____|____| / |____|____|____|____|
2. What is the date of the assessment (MM/DD/YYYY)?
|____|____| /
|____|____| /|____|____|____|____|
MONTH DAY
YEAR
3. Which assessment type?
Baseline
Reassessment (for clients in care at 3 or 6 months)
Annual (for clients in care for more than 12 months)
Record Closeout
4. [AT BASELINE ASSESSMENT ONLY] When did the client first receive services under this grant (MM/YYYY)? |____|____| / |____|____|____|____|
5. [AT REASSESSMENT OR ANNUAL OR CLOSEOUT] When did the client most recently receive services under this grant (MM/YYYY)? |___|___| / |___|___|___|___|
6. [AT RECORD CLOSEOUT] Why are you closing out this client’s record?
Completed the program
No contact
Withdrew from/Refused Treatment
Referred out
Transferred to different grant program
Incarceration
Moved
Death
Other
6a. [IF QUESTION 6 IS DEATH] What was the cause of death?
Suicide
Overdose
Other behavioral health cause
Other cause
Not documented in record
Not applicable
What insurance does the client or guarantor have? Select all that apply.
Medicare
Medicaid
Private Insurance or Employer Provided
TRICARE, CHAMPUS, CHAMPVA or other veteran or military health care
Indian Health Service Tribal Health Care
An assistance program [for example, a medication assistance program]
Any other type of health insurance or health coverage plan
None
Not documented in records or not documented in records using this standard
In the past 30 days, was the client admitted to a hospital?
Yes – Behavioral health reasons, for example mental health or substance use disorder
Yes – Other health reasons, for example injury or illness
No
Not documented in records or not documented in records using this standard
In the past 30 days, did the client visit an emergency department?
Yes – Behavioral health reasons, for example mental health or substance use disorder
Yes – Other health reasons, for example injury or illness
No
Not documented in records or not documented in records using this standard
In the past 30 days, did the client experience a behavioral health crisis or request crisis response, for example from 988 or 911?
Yes
No
Not documented in records or not documented in records using this standard
4a. [IF QUESTION 4 IS YES] What was the primary crisis issue?
Suicide risk
Other risk of harm to self or others (e.g. NSSI, homicidal thoughts)
Mental health
Substance use other than overdose
Overdose
Other
Not documented in records or not documented in records using this standard
In the past 30 days, did the client spend one or more nights at a residential behavioral health treatment facility, for example crisis stabilization or residential substance use disorder treatment facility, including for withdrawal management?
Yes
No
Not documented in records or not documented in records using this standard
[CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, was the client arrested, taken into custody, or detained?
Yes
No
Not documented in records or not documented in records using this standard
Not applicable
[CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, did the client spend one or more nights in jail or a correctional facility?
Yes
No
Not documented in records or not documented in records using this standard
Not applicable
[CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, has the client been on probation, parole, or intensive pretrial supervision for one or more days?
Yes
No
Not documented in records or not documented in records using this standard
Not applicable
Please indicate the client’s screening results, as documented in an individual clinical or client record (whether paper or electronic).
Within the past 30 days, was the client screened or assessed by your program for risk of suicidality?
Yes – Screening result was negative (no or low risk)
Yes – Screening result was positive (at risk)
No, not screened or assessed
Not documented in records or not documented in records using this standard
Within the past 30 days, was the client screened or assessed by your program for substance use?
Yes – Screening result was negative (no or low risk for substance use disorder (SUD))
Yes – Screening result was positive (at risk for SUD)
No, not screened or assessed
Not documented in records or not documented in records using this standard
[IF QUESTION 2 IS “YES”] During the screening and assessment process, what was the reported use for the following substances?
-
Substance
Recent use
(within the past 30 days)
Past use
(greater than 30 days)
Never used
Not documented
a. Alcohol
O
O
O
O
b. Opioids
O
O
O
O
c. Cannabis
O
O
O
O
d. Sedative, hypnotic, or anxiolytics
O
O
O
O
e. Cocaine
O
O
O
O
f. Methamphetamine
O
O
O
O
g. Other stimulants
O
O
O
O
h. Hallucinogens or psychedelics
O
O
O
O
i. Inhalants
O
O
O
O
j. Other psychoactive substances
O
O
O
O
k. Tobacco or nicotine
O
O
O
O
Within the past 30 days, was the client screened or assessed by your program for the following disorders? (Please select one per disorder)
-
Disorder
Not applicable
Screened / Assessed
Not screened
Not documented in records
a. Depression, depressive disorders
O
O
O
O
b. Anxiety disorders
O
O
O
O
c. Bipolar disorders
O
O
O
O
d. Psychosis, psychotic disorders
O
O
O
O
e. Trauma disorders, including PTSD
O
O
O
O
f. [IF CLIENT < 18 YEARS] Developmental, neurologic disorders
O
O
O
O
g. [IF CLIENT < 18 YEARS] Behavioral and emotional
O
O
O
O
Please indicate the client’s current behavioral health diagnoses using the most current version of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes or corresponding Diagnostic Statistical Manual of Mental Disorders (e.g. DSM-5), as made by a clinician and documented in a clinical record.
1. Substance use disorder diagnosis (record up to 3)
1a. Enter ICD-10-CM/DSM-5 code F10-F19- or indicate no diagnosis ______
1b. Enter ICD-10-CM /DSM-5 code F10-F19- or indicate no diagnosis ______
1c. Enter ICD-10-CM /DSM-5 code F10-F19- or indicate no diagnosis ______
Mental health diagnosis (record up to 3)
2a. Enter ICD-10-CM /DSM-5 code F20-F99- or indicate no diagnosis ______
2b. Enter ICD-10-CM /DSM-5 code F20-F99- or indicate no diagnosis ______
2c. Enter ICD-10-CM /DSM-5 code F20-F99- or indicate no diagnosis ______
Other factors influencing health status (record up to 3)
3a. Enter ICD-10-CM /DSM-5 code Z55-Z65- or Z69-Z76- or indicate none identified ______
3b. Enter ICD-10-CM /DSM-5 code Z55-Z65- or Z69-Z76- or indicate none identified ______
3c. Enter ICD-10-CM /DSM-5 code Z55-Z65- or Z69-Z76- or indicate none identified ______
Other Health Status Questions
Please indicate additional health status information as applicable and as documented in a clinical record.
Is the client currently pregnant?
Yes
No
Not applicable
Not documented in records or not documented in records using this standard
[CLINICAL HIGH RISK PSYCHOSIS CLIENTS ONLY]
[AT REASSESSMENT OR ANNUAL] Has the client experienced an episode of psychosis since their last assessment?
Yes
No
Not documented in records or not documented in records using this standard
[SUBSTANCE USE DISORDER TREATMENT CLIENTS ONLY]
In the previous 30 days, did the client experience an overdose or take too much of a substance that resulted in needing supervision or medical attention?
Yes
No
Not documented in records or not documented in records using this standard
Not applicable
6a. [IF QUESTION 6 IS YES] After taking too much of a substance or overdosing, what intervention(s) did the client receive? Select all that apply.
Naloxone (Narcan) or other opioid overdose reversal medication
Care in an emergency department
Care from a primary care provider
Admission to a hospital
Supervision by someone else
Other
Not documented in records or not documented in records using this standard
Not applicable
[MAI PROGRAM CLIENTS ONLY]
7. Has the client ever tested positive for HIV?
Yes, HIV-positive
No, HIV-negative
Not documented in records or not documented in records using this standard
7a. [IF 7 is Yes, HIV-infected] Is the client currently on ART?
Yes, currently taking ART
No, not currently taking ART
Not documented in records or not documented in records using this standard
7b. [If 7 is No, HIV-negative] Is the client currently taking HIV PrEP?
Yes, currently on PrEP
No, not currently on PrEP
Not documented in records or not documented in records using this standard
Has the client ever tested positive for Hepatitis C?
Yes, active or previous Hepatitis C infection
No, never had Hepatitis C
Not documented in records or not documented in records using this standard
8a. [IF 8 is Yes, active or previous Hep C] Is the client currently taking viral hepatitis C treatment?
Yes, currently taking viral hepatitis C treatment
No, took treatment and cured
No, hepatitis C infection naturally cleared without need for treatment
No, not currently taking treatment
Not documented in records or not documented in records using this standard
Services Received is collected by grantee staff at Reassessment, Annual Assessments and Closeout. |
Identify all the services your grant project provided to the client since their previous assessment.
1. Behavioral Health Services
Since the previous administrative assessment, did the project provide or refer the client for one or more behavioral health services?
Yes
No
Not documented in records
If Yes, please indicate which:
|
Yes – Provided |
Referred for Service |
No – Not Provided or Referred |
Not Documented in records / Unknown |
1a. Case or care management or coordination |
|
|
|
|
1b. Person- or family-centered treatment planning |
|
|
|
|
1c. Substance use psychoeducation |
|
|
|
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1d. Mental health psychoeducation |
|
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|
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1e. Mental health therapy |
|
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|
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1f. Co-occurring therapy (substance use & mental health) |
|
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1g. Group counseling |
|
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1h. Individual counseling |
|
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1i. Family counseling |
|
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1j. Psychiatric rehabilitation services |
|
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1k. Prescription medication for mental health disorder |
|
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1l. Medication for substance use disorder |
|
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1m. Intensive day treatment |
|
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1n. Withdrawal management (whether in hospital, residential, or ambulatory) |
|
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lo. After care planning and referrals |
|
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1p. Co-occurring disorders (including developmental or neurologic) |
|
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2. [IF 1m – Medication for substance use disorder IS YES – PROVIDED] Indicate medication received
|
Yes – Received |
No – Not Received |
Not Documented in records / Unknown |
2a. Naltrexone |
|
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2b. Extended-release Naltrexone |
|
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2c. Disulfiram |
|
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2d. Acamprosate |
|
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2e. Methadone |
|
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2f. Buprenorphine |
|
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2g. Nicotine cessation therapy (eg. Nicotine patch, gum, lozenge) |
|
|
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2h. Bupropion |
|
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2i. Varenicline |
|
|
|
2j. Other |
|
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|
3. Crisis Services
Since the previous administrative assessment, did the project provide or refer the client for one or more crisis services?
Yes
No
Not documented in records
If Yes, please indicate which:
|
Yes – Provided |
Referred for Service |
No – Not Provided or Referred |
Not Documented in Records / Unknown |
3a. Crisis response planning |
|
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|
|
3b. Crisis response |
|
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3c. Crisis stabilization |
|
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3d. Crisis follow-up |
|
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4. Recovery and Support Services
Since the previous administrative assessment, did the project provide or refer the client for one or more recovery support services?
Yes
No
Not documented in record
If Yes, please indicate which:
|
Yes – Provided |
Referred for Service |
No – Not Provided or Referred |
Not Documented in Records / Unknown |
4a. Employment support |
|
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|
4b. Family support services, including family peer support |
|
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4c. Childcare |
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4d. Transportation |
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4e. Education support |
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4f. Housing support |
|
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4g. Recovery housing |
|
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4h. Spiritual, ceremonial, and/or traditional activities |
|
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4i. Mutual support groups |
|
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4j. Peer support specialist services, coaching or mentoring |
|
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4k. Respite care |
|
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4l. Therapeutic foster care |
|
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|
5. Integrated Services
Since the previous administrative assessment, did the project provide or refer the client for one or more integrated services?
Yes
No
Not documented in records
If Yes, please indicate which:
|
Yes – Provided |
Referred for Service |
No – Not Provided or Referred |
Not Documented in Records / Unknown |
5a. Primary health care |
|
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|
5b. Maternal health care or OB/GYN |
|
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5c. HIV testing |
|
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5d. Viral hepatitis testing |
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5e. HIV treatment |
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5f. HIV pre-exposure prophylaxis (PrEP) |
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5g. Viral hepatitis treatment |
|
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5h. Other STI testing or treatment |
|
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5i. Dental care |
|
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F. DEMOGRAPHICS
Demographics is collected by grantee staff at Baseline only if the Client or Caregiver declined consent for the SUPRT-C.. |
If the individual declined the Client or Caregiver SUPT-C form at baseline, please provide demographic information below. These data can pulled from other internal sources, however it should still come directly from clients, with the exact categories or response options as indicated below, and not be assumed.
What is the client’s race or ethnicity? Select all that apply and enter additional details in the spaces below.
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.
Enter, 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. _____________________
Race/ethnicity not captured in grantee records using detailed OMB categories.
Client/caregiver declined to provide race/ethnicity
[IF CLIENT 12 YEARS OLD OR OLDER] What gender did the individual identify as?
Female
Male
I don’t know
Two-Spirit [If respondent is American Indian or Alaska Native]
Used a different term: [free text] _________
Preferred not to answer
Gender identity not captured in grantee records using above categories.
What was the individuals sex assigned at birth, for example on their original birth certificate?
Female
Male
Client doesn’t know
Preferred not to answer
Sex at birth not captured in grantee records using above categories.
[IF CLIENT 12 YEARS OLD OR OLDER] Which of the following best represents how the individual thinks of themselves?
Lesbian or gay
Straight or Heterosexual
Bisexual
Two-Spirit [If American Indian or Alaska Native]
Used a different term – Enter: _______________________
Client doesn’t know
Preferred not to answer
Sexual orientation not captured in grantee records using above categories.
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