Form CRSQ

Parent-Child Assistance Program

OMB # 0930- XXXX
Expiration Date: xx/xx/xxxx

COMMUNITY REFERRAL SCREENING QUESTIONNAIRE (CRSQ)
County:

Michigan Department of Community Health- Network 180

Michigan Department of Community Health- Lakeshore Coordinating Council

Southern California Alcohol and Drug Programs

Other:

______________________

Client ID:___________

Recruitment script read

Recruitment script for initial researcher contact with eligible mothers:
“INSERT RECRUITMENT SCRIPT TEXT HERE”

REFERRAL
SOURCE

Name/Position:

Phone:

Agency:
Address:
(include zip code)

Date of Referral: __ __/__ __/__ __ __ __
Mo Day Year
CLIENT
INFORMATION

Name:

Phone:

Address:
(include zip code)

How to contact:

Date of Screening: __ __/__ __/__ __ __ __
Mo Day Year

Demographics: Client DOB _______________
Age _____

Race _____________

PIC# ___________
# of Children (incl.Target Child whether or not born) ______

Marital Status _________________________
Native Language ______________

Highest Grade Completed in School _______

Speaks English? ___

US citizen or documented?____

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 OMB
control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 5 minutes per client per year, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1
Choke Cherry Road, Room 7-1044, Rockville, Maryland,20857.

Last Name: ________________

Community Referral Screening Questionnaire, pg 2

Date Screened: ________________
ELIGIBILITY FOR ENROLLMENT [Client must meet currently pregnant or within 6 months postpartum condition and alcohol condition to be
enrolled in PCAP]

1. PREGNANCY STATUS: Is client currently pregnant? [If yes go to Currently Pregnant section, if no go to Postpartum section]
Currently Pregnant
Estimated Gestational Age (GA): ______ weeks

Due Date:

Planned Hospital of Delivery:
ENROLLEES EARLY IN PREGNANCY MUST HAVE MULTIPLE INDICATORS OF HIGH-RISK.
Circle all that apply: Alcohol/drug abuse, Previous exposed pregnancy,
Previous children removed, Tx failures, Other:___________________________________

Postpartum
Date of Delivery:

Hospital of Delivery:

Complications:
• CURRENTLY PREGNANT OR WITHIN 6 MONTHS POSTPARTUM....................................................................... No, ....................................Yes
ineligible

( EARLY PREGNANCY WITH HIGH-RISK INDICATIONS)

2.

SELF-REPORT OF ALCOHOL OR DRUG USE DURING THIS PREGNANCY
Alcohol/Drug(s) of choice:
History of Problem (esp. during this pregnancy):
Name/Type of Drug:
Amount:
Frequency (circle one):

Daily

Weekly

Monthly

Positive Toxicology Screen(s):
Mother:

Baby:
• USED ALCOHOL DURING THIS PREGNANCY? ............................................................ No, ....................................Yes
ineligible
* ANY Alcohol use reported

3.

INVOLVEMENT WITH COMMUNITY SERVICES DURING PREGNANCY
Any Alcohol/Drug Tx now or during pregnancy? (describe):
Other Services:
AA, NA/other treatment support group?
Mental health services?
AIDS/HIV services?
Other supportive group/church?
Regular family doctor, OB/GYN?
Public health nurse?
CPS?
Public housing?
Legal services?
Domestic violence services?
Other program?
If connected to services, but only ineffectively, how so?

Last Name: ________________

Community Referral Screening Questionnaire, pg 3

Date Screened: ________________
Prenatal Care:
Where (name of clinic/physician):
G.A. at start: ______ weeks
Approx. # visits:
Any unusual factors in prenatal care? (e.g., prenatal care in jail, high-risk pregnancy?)
With which advocacy/case management-type programs is this woman already connected?
(Names, description of involvement)

Effectively
Yes, not
• NOT EFFECTIVELY CONNECTED WITH COMMUNITY SERVICES? ........................................................... connected, .....................effectively
Ineligible

OTHER NOTES/CONTACTS MADE: (include reason if referral is not eligible for enrollment, or eligible but not enrolled)

connected