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pdfOMB # 0930- XXXX
Expiration Date: xx/xx/xxxx
Parent Child Assistance Program (PCAP)
Date of ASI (A):
FADU, University of Washington
180 Nickerson, Seattle WA 98109 (206) 543-7155
________________
ADDICTION SEVERITY INDEX — INTAKE INTERVIEW
Family I.D. #
Adv #: _______
Mother's birthdate:
Interviewer:
Enrollment date:
Delivery Hospital:
Child's Gender:
Child's Due Date/Birthdate:
Gestational Age:
weeks
Mother's PIC #
Name of
child: (first)
Name of
mother: (first)
(last)
(middle)
(last)
(middle)
(last)
(middle)
(other)
(maiden/
other)
(nicknames/aliases)
Name of
father:
(first)
(other)
Who are you living with? Names and relationship:
Address:
City
Phone: (
)
State
Zip
Name phone listed under:
Do you have any plans to move in the next few months?
Are you employed outside the home now?
(Where to?)
Where?
Phone: (
Type of work:
Are you in school?
)
What/where?
Where did you go for prenatal care?
Where do you plan to take the baby for checkups and medical care?
INTERVIEWER: ASK FOR REFERENCES AT END OF INTERVIEW:
Could you give me the names of relatives or friends who might know your whereabouts if you move and we lose contact with you, or if there’s an emergency?
Name:
Name:
Address:
Address:
City, State, Zip:
City, State, Zip:
Phone:
(
)
Phone:
Name listed under:
Relationship to you:
(
Place of Employment:
(& phone)
)
Father of
Baby
Name:
Address:
City, State, Zip:
City, State, Zip:
(
)
Name listed under:
(
)
Phone:
(
)
Name listed under:
Relationship to you:
Place of Employment:
(& phone)
(
Name:
Address:
Phone:
)
Name listed under:
Relationship to you:
Place of Employment:
(& phone)
(
Relationship to you:
)
Place of Employment:
(& phone)
(
)
When you’re using, where are you likely to go, where might we find you?
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 2 hours and 45 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.
Addiction Severity Index 5th Edition
University of Washington Modification for Pregnant & Postpartum Women (UWASI)
The UWASI is a modified version of the 5th edition of the ASI. It
includes all items from the 5th edition ASI along with additional
questions specific to pregnant and postpartum women. It contains 9
potential problem areas, as well as family/childhood history.
INTRODUCING THE ASI: Introduce and explain the nine potential
problem areas: Medical, Employment/Support Status, Alcohol, Drug,
Legal, Family/Social, Psychiatric, Children and Family Planning, and
Community Services and that some questions will also be asked about
childhood history. All clients receive this same standard interview. All
information gathered is confidential; explain what that means in your
facility; who has access to the information and the process for the release
of information.
There are two time periods we will discuss:
1) The past 30 days
2) Lifetime
Client Rating Scale: Client input is important. For each area, I will ask
you to use this scale to let me know how bothered you have been by any
problems in each section. I will also ask you how important treatment is
for you for the area being discussed.
The scale is:
0 - Not at all
1 - Slightly
2 - Moderately
3 - Considerably
4 - Extremely
Inform the client that he/she has the right to refuse to answer any question.
If the client is uncomfortable or feels it is too personal or painful to give an
answer, instruct the client not to answer. Explain the benefits and
advantages of answering as many questions as possible in terms of
developing a comprehensive and effective treatment plan to help them.
Please try not give inaccurate information!
When you interview, do not simply record information. Be sure that you
understand the intent of every question on the ASI so that you can
accurately convey that intent to the client. Probe, repeat, paraphrase until
you are sure the client understands what is being asked. Remember that as
the interviewer, you are responsible for the integrity of information
collected on the ASI.
Monitor the consistency of information provided by the client throughout
the interview. It is not acceptable to simply record what is reported.
—Paraphrased from the Preface to the Fifth Edition of the ASI Workbook (Barbara
Fureman, Gargi Parikh, Alicia Bragg, and A. Thomas McLellan, University of
Pennsylvania/Veterans Administration Center for Studies of Addiction).
INTERVIEWER INSTRUCTIONS:
1) Leave no blanks.
2) Make plenty of Comments (if another person reads this ASI, they
should have a relatively complete picture of the client's perceptions of
his/her problems).
3) -7 = Question not answered.
-8 = Question not applicable
4) When noting comments, please write the question number.
HALF TIME RULE:
If a question asks the number of months, round
up periods of 14 days or more to 1 month.
Round up 6 months or more to 1 year.
CONFIDENCE RATINGS:⇒ Last two items in each section.
⇒ Do not over-interpret.
⇒ Denial does not warrant
misrepresentation.
⇒ Misrepresentation = overt
contradiction in information.
Probe, cross-check and make plenty of comments!
HOLLINGSHEAD CATEGORIES (Licit work only):
1. Higher execs, major professionals, owners of large businesses
2. Business managers, proprietors of medium-sized businesses
($60,000-$175,000), lesser professionals (e.g., optician, pharmacist,
social worker, teacher [licensed], personnel manager, registered nurse).
3. Administrative managers and personnel, (e.g., appraiser, chief clerk,
insurance agent, private secretary, major sales representative), owners/
proprietors of small businesses (value under $60,000; e.g., bakery,
beauty hop, cigarette machines, convenience store, engraving business,
florist, decorator), minor professionals (e.g., actor, commercial artist,
credit manager, oral hygienist, piano teacher, reporter, travel agent).
4. Clerical and sales (e.g., bank clerk or teller, bill collector, bookkeeper,
car sales person, clerical worker, ferry worker, post office clerk, sales
clerk, shipping or warehouse clerk, secretary), technician (e.g., camp
counselor, dental technician, inspector, investigator, PBX operator,
window trimmer), proprietor of little business (e.g., flower shop, food
vendor, newsstand, sewing/tailor).
5. Skilled manual (usually having had training). Baker, chef,
cosmetician, barber, chef, electrician, fireman, hair stylist, lineman,
locksmith, machinist, massage therapist, mechanic, paperhanger,
painter, plumber, policeman, postal carrier, repairman, tailor (trained),
word processing.
6. Semi-skilled. Apprentice (electrician, printer, etc.), assembly line
worker, bartender, bus driver, checker, childcare in home (licensed,
trained), cocktail waitress, convenience store clerk, cook (short order),
daycare in a center (trained), delivery person, dressmaker (machine),
filing clerk, garage and gas station attendant, hairdresser, hospital aide,
housekeeper (some training), meter reader, trained nursing home aide,
practical nurse, painter, security guard, taxi driver, truck driver,
waitress (at one of the “better” places).
7. Unskilled. Amusement park workers (bowling alleys, pool rooms),
attendant, cafeteria worker, car wash attendants, childcare in home (no
training), construction helper, counterperson, domestic, home aide
(unlicensed), home piecework, hotel maid (little training), hospital
worker (unspecified), janitor, labor (unspecified), laundry worker,
messenger, parking lot attendant, porter, telephone solicitor, stock
handlers, waitress (“hash house”), welfare recipient. Include
unemployed.
8. Never employed.
PSYCHIATRIC DIAGNOSES:
See appendix in UWASI manual (listing by category: p. xii - p. xvii; alphabetic
listing: p. xviii - p. xxii).
Note that FAS is a medical, not a psychiatric diagnosis.
ALCOHOL/DRUG USE INSTRUCTIONS:
Alcohol and Commonly Used Drugs: Drug terms and amounts. See appendix in
UWASI manual (p. vi - p. xi).
Code alcohol amounts by equivalent drinks:
Generally, 1 drink = 1 12-oz beer = 1 4-oz wine = 1 1.5-oz hard liquor (i.e., a
“single”). A single 40-ouncer is not 1 drink!
The following questions refer to two time periods: the past 30 days and lifetime.
Lifetime refers to the time prior to the last 30 days.
⇒ 30 day questions only require the number of days used.
⇒ Lifetime use is asked to determine extended periods of use.
⇒ Regular use = 3+ times per week, binges, or problematic irregular
use in which normal activities are compromised.
⇒ Alcohol to intoxication does not necessarily mean “drunk.” Use the
words “to feel or felt the effects,” “got a buzz,” “high,” etc. instead
of intoxication. As a rule of thumb, 3+ drinks in one sitting, or 5+
drinks in one day defines “intoxication.”
⇒ How to ask these questions:
→ “How many days in the past 30 have you used....?”
→ “How many years in your life have you regularly used....?”
PCAP Client Module
Addiction Severity Index 5th Edition - Intake Interview
Modification for Pregnant & Postpartum Women (Part A of 2 Parts)
Agency Name: ___________________________
Site Name: ______________________________
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
INSTRUCTIONS: Leave no blanks. Unless otherwise noted, where appropriate, code items:
-7 = Question not answered, client doesn’t know, doesn’t understand
-8 = Question not applicable
-9 = Question never asked
Space is provided at right for additional comments.
Assure client of confidentiality
GENERAL INFORMATION
A.
GENERAL INFORMATION COMMENTS
Target Child Due Date
__ __ /__ __ /__ __ __ __
If TC already born, list date of birth.
m
m
d
d
y
y
y
y
B.
Date of enrollment
Date consent signed
C.
Advocate #
___ ___ ___
D.
Referral Code
___ ___ ___
__ __ /__ __ /__ __ __ __
m
m
d
d
y
y
y
y
(Include the question number with your notes)
______________________________________________________
______________________________________________________
______________________________________________________
Name of source: ________________________
G5.
Date of interview
__ __ /__ __ /__ __ __ __
m
G6.
m
d
Time Begun
Time Ended
G9.
Contact Code
1 - PCAP Office
y
y
y
y
___ ___ : ___ ___
Use 24 hr clock; code hours:minutes
HRS
MINS
___
2 - Phone
5 - Other (tx center, client’s home)
___ ___ ___
G11.
Interviewer Code Number
G14.
How long have you lived at your current
address?
__ __ / __ __
Yrs
G16.
Date of birth of client
m
d
______________________________________________________
______________________________________________________
______________________________________________________
__ __ __ __ __
______________________________________________________
d
y
y
y
y
___ ___
G16a. Client’s Age
Race
Indicate for each: 0 - No, 1 - Yes
______________________________________________________
______________________________________________________
______________________________________________________
a. Am./Can. Indian
___
e. Alaska Native
___
b. Asian
___
f.
___
c. Black
___
g. White
___
h. Other (specify below)
___
______________________________________________________
Specify other: ________________________________
______________________________________________________
d. Native Hawaiian/ ___
Other Pacific IsIander
G18.
______________________________________________________
___
__ __ /__ __ /__ __ __ __
m
G17.
Mos
Is this residence owned by you or your family?
0 - No
1 - Yes
G15a. Zip code of client
______________________________________________________
______________________________________________________
Specify other: __________________________
G15.
______________________________________________________
___ ___ : ___ ___
Use 24 hr clock; code hours:minutes
G7.
d
______________________________________________________
Hispanic
______________________________________________________
___
Religious preference
1 - Protestant/Christian
4 - Islamic
2 - Catholic
5 - Other (specify below)
3 - Jewish
6 - None
______________________________________________________
______________________________________________________
Specify other: ___________________________
ADAI Sound Data Source—11/7/2006
http://adai.washington.edu/sounddatasource
Page 1
Parent-Child Assistance Program (PCAP)
University of Washington
180 Nickerson, Suite 309, Seattle, WA 98109
(206) 543-7155
(206) 685-2903
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
GENERAL INFORMATION (cont)
G18a. Do you go to church? How active are you?
0 - No, do not go
1 - Yes, but not very active
2 - Yes, but sometimes active
3 - Yes, and very active
GENERAL INFORMATION COMMENTS
___
______________________________________________________
______________________________________________________
Which church? _____________________________
G19.
Have you been in a controlled environment in the
past 30 days?
1 - No
4 - Medical tx
2 - Jail/prison
5 - Psychiatric tx
3 - Alcohol or drug tx
6 - Other (specify below)
______________________________________________________
___
______________________________________________________
______________________________________________________
Specify other: ___________________________
A place, theoretically, without access to alcohol/drugs; halfway house
generally not controlled environment. If more than one environment, code
where majority of time.
G20.
How many days?
Is client enrolled in PCAP under a Child Protective
Services (CPS) contract condition?
0 - No
1 - Yes
ADAI Sound Data Source—11/7/2006
Page 2
______________________________________________________
______________________________________________________
___ ___
TOTAL days of past 30 in ALL controlled settings.
If G19 is No, code -8.
G21.
(Include the question number with your notes)
______________________________________________________
___
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
MEDICAL STATUS
MEDICAL COMMENTS
(Include the question number with your notes)
Note: Restrict to physical medical problems only. Do
not include psychiatric problems, or physical problems
due only to alcohol or drug use (both will be recorded
elsewhere).
M1.
______________________________________________________
___ ___
How many times in your life have you been
hospitalized for medical problems?
Overnight, not simple E.R. Normal childbirth not counted, but complications in
childbirth are. Include o.d.’s, d.t.’s. Do not include detox, psych or rehab
hospitalization.
PROBE for injury, assault, car accident.
M2.
How long ago was your last hospitalization for
a physical problem?
Yrs
Mos
Do you have any chronic medical problems which
continue to interfere with your life? (Include FAS/FAE
diagnosis)
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Specify: ________________________________
Requiring continuous or regular care on the part of client, not a temporary
condition. Examples of chronic medical problems: ulcers, cirrhosis, heart
conditions, hepatitis, hypertension, AIDS-related problems, abscesses of the
arms/legs, etc.
Not minor allergies, need for reading glasses, etc.
To determine whether or not a medical problem is related only to drugs and
alcohol, (therefore not coded here), ask yourself, if she stopped using, would
this problem disappear without medical tx?
M4.
______________________________________________________
__ __ / __ __
If never hospitalized, then code -8/-8.
M3.
______________________________________________________
Are you taking any prescribed medication on a
regular basis for a physical problem?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
What? _________________________________
For above medical condition(s), legitimately prescribed, whether or not client
takes the med. Do not include meds for psychiatric conditions, or for shortterm or temporary conditions (like colds, detox), birth control pills, nicorette.
M4a.
___
Have you ever been tested for HIV/AIDS?
0 - Never tested
1 - Tested, negative results
2 - Tested, positive results
3 - Tested, inconclusive results
4 - Tested, never got results
-7 - Don’t know
__ __ / __ __
Date of last HIV/AIDS test (mo/yr)
M4c.
Have you ever been tested for Hepatitis B?
Use codes from M4a
___
M4d.
Have you ever been tested for Hepatitis C?
Use codes from M4a
___
M4e.
Have you worked as a prostitute in the last 3 years
(for either drugs or money)?
0 - No
1 - Yes
___
Year
Do you receive a pension for a physical disability?
0 - No
1 - Yes
How many days have you experienced medical
problems in the past 30 days?
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___
______________________________________________________
Includes Worker’s Comp.
Does not include psychiatric disability.
M6.
______________________________________________________
______________________________________________________
Specify: ________________________________
M5.
______________________________________________________
______________________________________________________
M4b.
Mo
______________________________________________________
______________________________________________________
___ ___
______________________________________________________
Include only medical problems that would be present even if the client were to
become abstinent.
Include minor ailments such as colds or flu.
______________________________________________________
For Questions M7 & M8, ask client to use the Client’s Rating Scale
Have client restrict her responses to only those medical problems counted in M6.
M7.
How troubled or bothered have you been by these
medical problems in the past 30 days?
___
M8.
How important to you now is treatment for these
medical problems?
___
ADAI Sound Data Source—11/7/2006
Page 3
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
MEDICAL STATUS (cont)
MEDICAL COMMENTS
(Include the question number with your notes)
CONFIDENCE RATINGS
Is the above information significantly distorted by:
M10. Client’s misrepresentation?
0 - No
1 - Yes
______________________________________________________
___
______________________________________________________
In all sections this means contradictory information has been presented by the
client, conflicting reports that the client cannot justify.
______________________________________________________
It does not mean a simple “gut hunch.” Disregard client’s demeanor.
M11. Client’s inability to understand?
0 - No
1 - Yes
___
______________________________________________________
INTERVIEWER CLIENT NEED RATING
M99. How would you rate this client’s need for
medical treatment?
___
______________________________________________________
01-
No medical problems, no need.
Medical problems, but current tx has brought condition to a
controlled, non-problematic state.
2-
Need for more tx in addition to client’s current tx, but not
immediately life-threatening.
______________________________________________________
3-
Urgent need for more tx in addition to client’s current tx. Should
be a high advocate priority.
______________________________________________________
ADAI Sound Data Source—11/7/2006
Page 4
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
EMPLOYMENT/SUPPORT STATUS
E1.
Education completed
EMPLOYMENT/SUPPORT COMMENTS
__ __ / __ __
Code GED 55 yrs, 00 mos
Yrs
Mos
If more than GED, code highest level; formal education only
E2.
Training or technical education completed
__ __
Formal, organized training only
E3.
___
Do you have a profession, trade, or skill?
0 - No
1 - Yes
______________________________________________________
______________________________________________________
___
E4a. Do you have another form of picture identification?
0 - No
1 - Yes
Must be legal, not forged or borrowed.
___
E5.
___
______________________________________________________
Do you have an automobile available for use?
0 - No
1 - Yes
______________________________________________________
If answer to E4 is No, then E5 must be No.
Does not require ownership, only requires availability on a regular basis.
___
E5a. How do you usually get around?
1 - Own car
5 - Taxi
2 - Use friend/relative’s car
6 - Walk
3 - Rides from friends/relatives
7 - Other
4 - Bus
Specify other: ______________________________
How long was your longest full-time job?
______________________________________________________
__ __ / __ __
Mos
______________________________________________________
______________________________________________________
___
Usual (or last) occupation
Specify in detail: ______________________________
______________________________________________________
Code appropriate Hollingshead Category.
No usual occupation, record last job.
Code 8 only when client has not worked at all.
______________________________________________________
Does someone (a person) contribute to your
support in any way?
0 - No
1 - Yes
___
Does this support constitute the majority of
your support?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
If E8 is No, then E9 is -8. If information from E12-E17 does not confirm this
initial response, clarify any discrepancy.
______________________________________________________
___
E10. Usual employment pattern, past 3 years
5 - Military service
6 - Retired/disability
7 - Unemployed
8 - In controlled environment
Most representative, not necessarily most recent. If equal times for more than
one category, code most current. Includes "under the table" jobs. Jobs in prison
are not counted as employment.
E11. How many days were you paid for working in
the past 30?
______________________________________________________
______________________________________________________
Regular support in form of cash, housing, food.
Include spouse's contribution.
Exclude institutionalized support.
1 - Full time (> 35 hrs/wk)
2 - Part time (regular hrs)
3 - Part time (irregular, daywork)
4 - Student
______________________________________________________
______________________________________________________
Yrs
E9.
______________________________________________________
______________________________________________________
E4b. Is transportation usually a problem for you?
0 - No
1 - Yes
E8.
______________________________________________________
___
Do you have a valid driver’s license?
0 - No
1 - Yes
Valid license; not suspended/revoked.
E7.
______________________________________________________
______________________________________________________
Specify in detail: __________________________________
E6.
______________________________________________________
Mos
Any employable, transferable skill acquired through specialized training or
education.
E4.
(Include the question number with your notes)
___ ___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Include paid sick/vacation days, “under-the-table” work.
Jobs in prison are NOT counted.
ADAI Sound Data Source—11/7/2006
Page 5
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
EMPLOYMENT/SUPPORT STATUS (cont)
EMPLOYMENT/SUPPORT COMMENTS
How much money did you receive from the following sources
in the past 30 days?
______________________________________________________
Remind client of confidentiality if client is reluctant to answer.
Focus here is on amount of CASH available to client, not
on estimate of client’s net worth.
E12.
Employment
Net income, take home pay, include “under the table”
$___,___ ___ ___
Unemployment compensation
$___,___ ___ ___
E14.
Welfare
$___,___ ___ ___
Specify Type(s): _____________________
$___,___ ___ ___
E15.
$___,___ ___ ___
Pensions for disability, SSI, worker’s comp
$___,___ ___ ___
Specify Tribe: _______________________
E16.
Mate, family or friends (cash)
Money for personal expenses, pocket money
Settlements, legal gambling, income tax refund
Illegal (Cash only)
Do not attempt to convert drugs to cash
E18.
$___,___ ___ ___
How many people depend on you for the majority
of their food, shelter, etc.?
___ ___
Regular ongoing support. Do not include client herself or a self-supporting
spouse. Do include dependents who normally are supported by client but have
not been recently.
NOTE:
E19.
In the case where the client has not had an opportunity to work (incarcerated,
in treatment, etc.), it is, by definition, not possible for her to have had
employment problems. Therefore, code -8’s for E19-E21.
How many days have you experienced employment
problems in the past 30?
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
For Questions E20 & E21, ask client to use the Client’s Rating Scale
How troubled or bothered have you been by these
employment problems?
______________________________________________________
___ ___
Include problems finding work only if client has been trying. Do not record here
if problems are entirely due to alcohol/drug use (record in Alcohol/Drug
section), or if they are entirely due to interpersonal social skills (record in
Family/Social section).
E20.
______________________________________________________
______________________________________________________
$___,___ ___ ___
ALSO Irregular sources of income
E17.
______________________________________________________
______________________________________________________
E14a. Food stamps
E15a. Tribal benefits
______________________________________________________
______________________________________________________
E13.
Pension, benefits or social security
(Include the question number with your notes)
______________________________________________________
______________________________________________________
___
______________________________________________________
Restrict to those identified in E19.
E21.
How important to you now is counseling for these
employment problems?
___
______________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
E23.
E24.
Client’s misrepresentation?
0 - No
1 - Yes
Client’s inability to understand?
0 - No
1 - Yes
___
______________________________________________________
___
______________________________________________________
INTERVIEWER CLIENT NEED RATING
E99.
How would you rate this client’s need for employment
counseling?
______________________________________________________
___
______________________________________________________
0-
No employment problems, working, no need.
1-
No employment problems because no employment, client not
currently ready for employment.
______________________________________________________
23-
Employment problems, employed.
Employability problems, unemployed.
______________________________________________________
ADAI Sound Data Source—11/7/2006
Page 6
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
ALCOHOL/DRUG USE (ILLICIT & PRESCRIPTION)
ALCOHOL/DRUG COMMENTS
• Include licit, prescription drugs in appropriate categories. If only drug used in that category is prescription, code 1 in
“prescription only” box (otherwise-0).
• Ask past 30 days first. Lifetime use=extended period of regular use (regular use=freq. of ≥3 times/week OR any use over a
period of time that is problematic for the client, e.g. binge use). If total period of reg. use less than 6 months do not include in
coding, but note in comments section. Six months or more counts to the next year. Substantial but irregular, non-problematic
use is not coded, but is noted in comments section.
• Alcohol to Intoxication is not necessarily getting drunk, but times client felt effect of alcohol, got a buzz. If client denies feeling
effects of alcohol: the equivalent of 3 drinks in one sitting (1–2 hours) can be considered alcohol to intoxication.
• Age at first use for alcohol, exclude a few sips.
• If past 30 day and lifetime use = 0, then all other columns should be coded -8.
• NOTE: Anti-depressants are noted in comments, but not recorded on grid.
(Include the question number with your notes)
D1.
D3.
___ ___
___
___ ___
__ __ /__ __ __ __
Alcohol (to intoxication)
___ ___
___ ___
___
___ ___
__ __ /__ __ __ __
______________________________
Heroin
___ ___
___ ___
___
___ ___
__ __ /__ __ __ __
______________________________
___ ___
___ ___
___
___
___ ___
__ __ /__ __ __ __
______________________________
___ ___
___ ___
___
___
___ ___
__ __ /__ __ __ __
______________________________
___ ___
___ ___
___
___
___ ___
__ __ /__ __ __ __
Methadone
Other opiates/analgesics
Morphine, Demerol, Percocet, Darvon,
Codeine, Robitussin
D6.
Cocaine - all forms
Crack, freebase, base, rock, coke powder,
soup, crack, candy, line
D9.
Methamphetamine
Crank, crystal meth, chalk, L.A.
D9a.
Other amphetamines
Speed, race, ice, white cross, amp
D10.
Cannabis (Marijuana)
Weed, pot, bud, grass, hashish
D11.
___ ___
___ ___
___
___ ___
___ ___
___ ___
___
______________________________
___ ___
__ __ /__ __ __ __
___
___ ___
__ __ /__ __ __ __
______________________________
___ ___
___
___ ___
__ __ /__ __ __ __
______________________________
___ ___
___ ___
___
___ ___
__ __ /__ __ __ __
______________________________
___ ___
___ ___
___
___ ___
__ __ /__ __ __ __
______________________________
___ ___
___ ___
___
___ ___
__ __ /__ __ __ __
___
Hallucinogens
______________________________
______________________________
LSD, acid, Mescaline, Mushrooms,
Psylocybin, PCP (Phencyclidine), angel
dust, Peyote, PMA
D12.
______________________________
______________________________
Other sed/hyp/tranquilizers
Valium, Librium, Thorazine, Tofranil,
Quaaludes
D8.
F.
Last Time Ever Used
(Mo/Yr)
______________________________
Barbiturates
Downers, reds, Seconal, Amytal,
Phenobarbitol
D7.
______________________________
___ ___
Alcohol (any use at all)
LAAM, Dolophine
D5.
______________________________
B.
Lifetime
(Years)
Smack, horse, dove, china white, tar
D4.
______________________________
A.
Past 30
Days
Wine coolers, beer, Cisco
D2.
D.
C. Prescription
Only
Route
E.
of
0 - No
Age at
Admin 1 - Yes First Use
______________________________
______________________________
Inhalants
Nitrous Oxide, Amyl Nitrate, Poppers, glue,
solvents
___ ___
___ ___
___
___ ___
__ __ /__ __ __ __
______________________________
NOTE: List ingredients of Other drug if known
D12a. Other (illicit only)
e.g., “club” drugs (ecstasy, etc.), steroids,
formaldehyde
Specify: __________________________
___ ___
___ ___
___
___ ___
__ __ /__ __ __ __
___ ___
___ ___
___
___ ___
__ __ /__ __ __ __
More than one substance per day ___ ___
Includes alcohol, but not cigarettes
___ ___
D12b. Cigarettes or chewing tobacco
______________________________
______________________________
______________________________
D13.
Routes of Admin:
1 - Oral
2 - Nasal (sniff, snort)
3 - Smoking
4 - Non IV inj (skin popping)
5 - IV injection
If more than one route of administration, choose most severe (i.e., highest applicable code)
D14. Which substance is the major problem?
______________________________
___ ___
______________________________
Interviewer determines this. When not clear, ask client.
00 - No problem
01 - Alcohol
07 - Other sed/hyp/tranquilizers
08 - Cocaine
13 - Other
15 - Alcohol & Drug (dual addiction)
03 - Heroin
09 - Amphetamines
16 - Polydrug (Alcohol no problem)
04 - Methadone
10 - Cannabis
05 - Other opiates/analgesics 11 - Hallucinogens
06 - Barbiturates
______________________________
______________________________
12 - Inhalants
ADAI Sound Data Source—11/7/2006
Page 7
______________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
ALCOHOL/DRUG USE (cont)
D15.
ALCOHOL/DRUG COMMENTS
How long was your last period of voluntary
abstinence from this major substance?
___ ___
Mos
Most recent attempt (of at least 1 month) to stay clean of major drug(s) of
choice. Do not count periods of incarceration or hospitalization. Methadone,
Antabuse, or Naltrexone as outpatient okay.
PROMPT: "When was the last time you were clean for at least a month?"
00 - Never abstinent
D16.
How many months ago did this abstinence end?
___ ___
Mos
If item D14 coded (15) alcohol & drug problem, abstinence must be from both
alcohol & drugs. If item D14 coded (16) polydrug, abstinence need not include
alcohol.
00 - Still abstinent
-8 - Never a period of abstinence
D16a. Questions about your alcohol use (T-ACE):
1. How many drinks does it take to make you
feel high (Tolerance)?
___ ___
2. Have people Annoyed you by criticizing
your drinking? 0 - No
1 - Yes
___
3. Have you felt you ought to Cut down on
your drinking? 0 - No
1 - Yes
___
4. Have you ever had a drink first thing in the
morning to steady your nerves or get rid of a
1 - Yes
hangover (Eye opener)? 0 - No
___
4. Being hospitalized?
5. *Other alcohol, specify:
____________________________
___
___
___
___
6. *Other drug, specify:
____________________________
___
___
How many times have you had alcohol d.t.’s?
___ ___
Not just “the shakes”
How many times have you overdosed on drugs?
___ ___
O.D. requires intervention. “Sleeping it off” doesn’t count.
Include suicide attempt with overdose (also code attempt in
Psychiatric).
D19.
How many times in your life have you been treated for:
Alcohol abuse, any type tx
___ ___
Code # tx episodes
D20.
Drug abuse, any type tx
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
*e.g., inability to care for children, auto accident, lost contact with family, etc.
D18.
______________________________________________________
______________________________________________________
D16b. Have you ever had any of the following problems because of
your alcohol/drug use?
0 - No
1 - Yes
A. Alcohol
B. Drugs
1. Having a relationship break up?
___
___
2. Getting arrested?
___
___
3. Losing a job?
___
___
D17.
(Include the question number with your notes)
___ ___
Code # tx episodes
How many times in your life have you had inpatient treatment for:
D20a. Alcohol abuse
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
# times; Code 6 if > 6
D20b. Drug abuse
___
______________________________________________________
# times; Code 6 if > 6
How many times in your life have you had outpatient treatment for:
D20c. Alcohol abuse
# times; Code 6 if > 6
D20d. Drug abuse
___
# times; Code 6 if > 6
For D19 and D20, any type tx includes inpatient, outpatient, detox, halfway
house, and/or AA/NA (if ≥3 session/mo.). For D19, D20, D20a-D20d, if tx for
alcohol and drugs simultaneously, count both places.
D21.
How many of these were detox only?
Alcohol
___ ___
Referring to D19. If D19 = 0, then D21 = -8
D22.
Drug
______________________________________________________
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___ ___
Referring to D20. If D20 = 0, then D22 = -8
ADAI Sound Data Source—11/7/2006
Page 8
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
ALCOHOL/DRUG USE (cont)
ALCOHOL/DRUG COMMENTS
How much money would you say you spent during the past 30
days on:
D23.
Alcohol
$___,___ ___ ___
D24.
Drugs
$___,___ ___ ___
(Include the question number with your notes)
______________________________________________________
______________________________________________________
Enter only money actually spent, not street value.
D25.
How many days have you been treated in an
outpatient setting for alcohol or drugs in the
past 30 days?
___ ___
______________________________________________________
______________________________________________________
Include NA, AA, meth. maint.
______________________________________________________
How many days in the past 30 have you experienced:
D26.
Alcohol problems
___ ___
D27.
Drug problems
___ ___
Only problems directly related to use, e.g., cravings, withdrawal, disturbing
effects, wanting to stop and not being able to.
For Questions D28 - D31, ask client to use the Client’s Rating Scale
How troubled or bothered have you been in the past 30 days by
these:
D28.
Alcohol problems
___
D29.
Drug problems
___
D30.
Alcohol problems
___
D31.
Drug problems
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
How important to you now is treatment for these:
______________________________________________________
______________________________________________________
CONFIDENCE RATINGS
______________________________________________________
Is the above information significantly distorted by:
D34.
D35.
Client’s misrepresentation?
0 - No
1 - Yes
Client’s inability to understand?
0 - No
1 - Yes
___
______________________________________________________
___
______________________________________________________
INTERVIEWER CLIENT NEED RATING
How would you rate this client’s need for treatment for:
______________________________________________________
D99a. Alcohol Abuse
___
D99b. Drug Abuse
___
0-
No alc/drug problems, no need (can include those currently
successfully maintaining abstinence with no tx currently
needed).
1-
Alc/drug problems, current tx seems adequate.
2-
Need for more tx in addition to current tx. High advocate priority.
3-
Urgent need for more alc/drug tx in addition to client’s current (if
any) tx. Highest advocate priority.
ADAI Sound Data Source—11/7/2006
Page 9
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
LEGAL STATUS
L1.
LEGAL COMMENTS
Was this admission prompted or suggested by
the criminal justice system (judge, probation/
parole officer, etc.)?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
Not CPS. Record CPS condition in item G21.
L2.
(Include the question number with your notes)
___
Are you on probation or parole?
0 - No
1 - Yes
How many times in your life have you been arrested and
charged with the following? (Not necessarily convictions)
______________________________________________________
______________________________________________________
L3.
Shoplifting/Vandalism
___ ___
L4.
Parole/Probation Violations
___ ___
L5.
Drug Charges
___ ___
L6.
Forgery
___ ___
L7.
Weapons Offense
___ ___
L8.
Burglary/Larceny/Breaking & Entering
___ ___
L9.
Robbery
___ ___
L10.
Assault
___ ___
L11.
Arson
___ ___
L12.
Rape, Sexual Assault
___ ___
L13.
Homicide/Manslaughter
___ ___
L14.
Prostitution
___ ___
______________________________________________________
L15.
Contempt of Court
___ ___
______________________________________________________
L16.
Other: ___________________________________
___ ___
L17.
______________________________________________________
______________________________________________________
Major driving violations
Reckless driving, speeding, no license, etc.
Does not include non-moving violations.
L20a. How many times in your life have you been
incarcerated?
How many months were you incarcerated in your
life (total months)?
Whether or not charge resulted in a conviction. Includes jail,
detention center, prison.
2 weeks or longer=1 month. <2 wks=000.
How long was your last incarceration? (most
recent)
Code -8 if never incarcerated.
What was it for?
Use codes 3–16, 18–20
If multiple charges, code most severe
Code -8 if never incarcerated.
ADAI Sound Data Source—11/7/2006
______________________________________________________
______________________________________________________
______________________________________________________
How many times in your life have you been charged with the
following:
Disorderly conduct, vagrancy, public intoxication
___ ___
Generally a public annoyance without the commission of a
L20.
Page 10
______________________________________________________
______________________________________________________
particular crime.
L23.
______________________________________________________
___ ___
How many of these charges resulted in
convictions?
Driving while intoxicated
L22.
______________________________________________________
______________________________________________________
L19.
L21.
______________________________________________________
Include only formal charges, not times when client was simply picked up and
questioned.
Code failure to appear as Other and note original charge in comments.
Do not include juvenile charges (<18 yrs) unless she was tried as an adult (but
do note juvenile charges in comments).
Include charges in L3–L16 above. Do not include charges in L18–L20.
Convictions include fines, probation, suspended sentences, charges for
probation/ parole violations, as well as incarceration.
If L3 through 16=00, then L17=-8
L18.
______________________________________________________
______________________________________________________
______________________________________________________
___ ___
______________________________________________________
___ ___
______________________________________________________
___ ___
___ ___ ___
______________________________________________________
______________________________________________________
Mos
______________________________________________________
___ ___
Mos
___ ___
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
LEGAL STATUS (cont)
L23b. How long was your longest incarceration? (longest
in life)
LEGAL COMMENTS
___ ___
Mos
______________________________________________________
Code -8 if never incarcerated.
L24.
___
Are you presently awaiting charges, trial, or
sentence?
0 - No
1 - Yes
______________________________________________________
Do not include civil charges.
L25.
___ ___
What for?
If multiple charges, code most severe.
Refers to L24. Use codes 3–16, 18–20.
Code -8 if not awaiting charges.
L26.
How many days in the past 30 were you detained or
incarcerated?
___ ___
______________________________________________________
______________________________________________________
___
L26a. Is client currently in jail/prison?
0 - No
1 - Yes
Specify: ______________________________
How many days in the past 30 have you engaged in
illegal activities for profit?
______________________________________________________
______________________________________________________
Include being detained (e.g., arrested but released on the
same day).
L27.
(Include the question number with your notes)
______________________________________________________
______________________________________________________
___ ___
______________________________________________________
Drug dealing, prostitution, burglary, selling stolen goods, etc.
NOT simple drug possession or drug use.
Cross-check with E17.
______________________________________________________
For Questions L28 & L29, ask client to use the Client’s Rating Scale
L28.
How serious do you feel your present legal
problems are?
___
Do not include civil problems (e.g., custody fights, divorce, etc.).
L29.
How important to you now is counseling or referral
for these legal problems?
______________________________________________________
______________________________________________________
___
______________________________________________________
Need for additional referral.
CONFIDENCE RATINGS
______________________________________________________
Is the above information significantly distorted by:
L31.
Client’s misrepresentation?
0 - No
1 - Yes
___
______________________________________________________
L32.
Client’s inability to understand?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
INTERVIEWER CLIENT NEED RATING
L99.
How would you rate the client’s need for legal
services or counseling? (Can include civil problems)
______________________________________________________
0-
No legal problems, no need.
1-
Legal problems, but currently receiving adequate services.
______________________________________________________
2-
Need for more legal assistance than client is currently
connected to.
______________________________________________________
3-
Urgent need for more legal assistance than client is currently
connected to. High advocate priority.
ADAI Sound Data Source—11/7/2006
Page 11
___
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY HISTORY (BIOLOGICAL RELATIVES ONLY)
Have any of your relatives had what you would call a significant drinking, drug use or psychiatric problem — one that did or should have led to tx?
0 - Clearly NO for all relatives in the category
1 - Clearly YES for any relative within category
-7 - Uncertain or “I don’t know”
-8 - Never was a relative in that category
In cases of more than one family member per category, code most problematic (most severe case).
EXCEPT FOR BABY’S FATHER, BIOLOGICAL RELATIVES ONLY.
Mother’s Side
Alc
Drug
Psych
H1.
Grandmother
___
___
H2.
Grandfather
___
H3.
Mother
H4.
H5.
Father’s Side
Alc
Drug
Psych
Siblings
Alc
Drug
Psych
___
H6.
Grandmother
___
___
___
H11.
Brother
___
___
___
___
___
H7.
Grandfather
___
___
___
H12.
Sister
___
___
___
___
___
___
H8.
Father
___
___
___
Aunt
___
___
___
H9.
Aunt
___
___
___
Alc
Drug
Psych
Uncle
___
___
___
H10.
Uncle
___
___
___
___
___
___
H13.
Baby’s Father
FAMILY HISTORY COMMENTS
(Include the question number with your notes)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
ADAI Sound Data Source—11/7/2006
Page 12
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
CHILDHOOD HISTORY COMMENTS
CHILDHOOD HISTORY
C1.
Were you raised part or all of the time by foster
parents or relatives (other than your parents)?
0 - No
1 - Yes, two years or less
2 - Yes, more than two years
___
______________________________________________________
______________________________________________________
Who? __________________________________
C2.
Were you ever in the foster care system? (as a child)
0 - No
1 - Yes
___
C3.
Was CPS involved? 0 - No
___
C4.
Were you ever adopted? 0 - No
C4a.
1 - Yes
1 - Yes
Age at adoption
If never adopted, code -8
If adopted at birth, code 00
C5.
Did you graduate from high school?
0 - No
1 - Yes
C6.
C6a.
______________________________________________________
______________________________________________________
___
___ ___
______________________________________________________
Yrs
______________________________________________________
___
______________________________________________________
GED = 0
C5a.
(Include the question number with your notes)
___
______________________________________________________
C5b. IF NOT because of pregnancy, why? __________________
______________________________________________________
IF NOT, was it because of pregnancy?
0 - No
1 - Yes
-8 - N/A
Did you ever run away from home as a child?
0 - Never
1 - Yes, once or twice
2 - Yes, frequently
IF YES, how old were you when you first ran away?
If never ran away, code -8
___
______________________________________________________
___ ___
Yrs
C7.
As a child, were you ever hit or beaten?
0 - No
1 - Yes, once or twice
2 - Yes, repeated times
___
C7a.
IF YES, was it ever bad enough to require
hospitalization or a visit to the doctor/ER?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
If never hit or beaten as child, code -8
C8.
As a child, were you ever raped?
0 - No
1 - Yes, once or twice
2 - Yes, repeated times
C8a.
IF YES, how old were you the first time?
If never raped as a child, code -8
C9.
C9a.
As a child, were you ever sexually used or molested
in any way besides rape?
0 - No
1 - Yes, once or twice
2 - Yes, repeated times
IF YES, how old were you the first time?
If never as a child, code -8
C10.
C11.
______________________________________________________
Yrs
___
___ ___
___
ADAI Sound Data Source—11/7/2006
______________________________________________________
______________________________________________________
______________________________________________________
___ ___
Yrs
______________________________________________________
___
______________________________________________________
0 - No
1 - Yes, light drinker
2 - Yes, heavy drinker
-7 - Don’t know
4 - No information on natural mother
Page 13
______________________________________________________
Yrs
Is your natural mother alive?
0 - No
1 - Yes
C12a. Did she drink alcohol while she was pregnant with you?
0 - No
1 - Yes, light drinker
2 - Yes, heavy drinker
-7 - Don’t know
4 - No information on natural mother
______________________________________________________
______________________________________________________
___
Did she drink alcohol when you were young?
______________________________________________________
___ ___
As a child, did you experience serious emotional
abuse?
0 - No
1 - Yes
C11a. IF NOT, how old were you when she died?
00 - At birth
-7 - Don’t know
-8 - Mother still alive
C12.
___
______________________________________________________
___
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
CHILDHOOD HISTORY (cont)
CHILDHOOD HISTORY COMMENTS
(Include the question number with your notes)
CONFIDENCE RATINGS
Is the above information significantly distorted by:
______________________________________________________
C13.
Client’s misrepresentation?
0 - No
1 - Yes
___
C14.
Client’s inability to understand?
0 - No
1 - Yes
___
ADAI Sound Data Source—11/7/2006
Page 14
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY/SOCIAL RELATIONSHIPS
FAMILY/SOCIAL COMMENTS
(Include the question number with your notes)
Note: Purpose of section is to assess inherent relationship
problems, not the extent to which alc/drugs have affected
relationships. Do not include here social/family problems due
solely to client’s substance abuse. In general, ask client: if
the alc/drug problem were absent, would there still be a
relationship problem?
F1.
______________________________________________________
______________________________________________________
___
Marital Status
1 - Married
2 - Remarried
3 - Widowed
4 - Separated
5 - Divorced
6 - Never married
______________________________________________________
Consider common-law (> 7 yrs) as married and specify in comments.
F2.
How long have you been in this marital status?
If never married, since age 18.
F3.
______________________________________________________
__ __ / __ __
Yrs
Mos
______________________________________________________
___
Are you satisfied with this situation?
0 - No
1 - Indifferent
2 - Yes
______________________________________________________
Satisfied=client generally likes situation, not simply
resigned to it.
F3a.
______________________________________________________
How would you describe your current housing
___ ___
situation?
01 - Permanent/stable (incl. Sec 8 if
05 - Long-term jail or prison
______________________________________________________
______________________________________________________
perm. res.)
F3b.
02 - Transient, emergency shelters
06 - Trans. drug-free housing
03 - Living w/ friend/relative temporarily
07 - Drug/alc tx facility
04 - Homeless (without shelter)
08 - Other (specify below)
Specify other: ________________________________
______________________________________________________
___ ___
______________________________________________________
How many times have you moved in the past
year?
Code 66 if homeless or too many moves to count
F4.
___ ___
Usual living arrangements (past 3 years)
01 - With sexual partner & children
02 - With sexual partner alone
03 - With children alone
04 - With parents
05 - With family
06 - With friends
07 - Alone
08 - Controlled environment
09 - No stable arrangements
If client lived in several arrangements, choose most representative. If time is
evenly split, choose most recent. Time spent in prisons, institutions, hospitals
is coded 08.
F5.
How long have you lived in these arrangements?
If with parents or family, since age 18.
F6.
Yrs
Mos
F7.
Uses non-prescribed drugs?
______________________________________________________
With whom do you spend most of your free time:
1 - Family
2 - Friends
3 - Alone
___
F10.
Are you satisfied with spending your free time
this way? (generally likes)
0 - No
1 - Indifferent
2 - Yes
___
How many close friends do you have?
___
Stress that you mean CLOSE.
Does not include family, or boyfriend/girlfriend considered
to be family/spouse.
ADAI Sound Data Source—11/7/2006
______________________________________________________
___
F9.
Page 15
______________________________________________________
___
Or abuses prescribed drugs
Whether problematic or not
F7 and F8 do not refer to neighborhood, just who lives in residence with client.
If in treatment or incarcerated, household to which client expects to return.
F11.
______________________________________________________
______________________________________________________
1 - Yes
i.e., a drinking alcoholic
F8.
______________________________________________________
______________________________________________________
2 - Yes
Do you live with anyone who:
0 - No
Has a current alcohol problem?
______________________________________________________
___
(generally likes)
1 - Indifferent
______________________________________________________
__ __ / __ __
Are you satisfied with these living arrangements?
0 - No
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY/SOCIAL RELATIONSHIPS (cont)
FAMILY/SOCIAL COMMENTS
(Include the question number with your notes)
Direction for F12 - F26:
______________________________________________________
Include biologic and adoptive relatives.
0 - Clearly NO for all persons in the category
______________________________________________________
1 - Clearly YES for any person within category
-7 - Uncertain or “I don’t know”
-8 - Never was a person in that category
______________________________________________________
Would you say you have had a close, long-lasting relationship
with any of the following people in your life:
F12.
Mother
___
F13.
Father
___
F14.
Brothers/Sisters
___
F15.
Sexual Partner/Spouse
___
F16.
Children
___
F17.
Friends
___
A simple yes here is not adequate. Probe to determine if there has been the
ability to feel closeness and mutual responsibility in the relationship. Does
client feel sense of value for the person (beyond simple self-benefit)?
Have you had a significant period in which you experienced
serious problems getting along with:
Past 30 Days In Your Life
F18.
Mother
___
___
F19.
Father
___
___
F20.
Brothers/Sisters
___
___
F21.
Sexual Partner/Spouse
___
___
F22.
Children
___
___
F23.
Other significant family
Who: _______________________
___
___
F24.
Close Friends
___
___
F25.
Neighbors
___
___
F26.
Co-Workers
___
___
F27.
2 - Yes, repeated times
Past 30 Days In Your Life
Emotionally?
Make you feel bad through harsh words
F28.
Physically?
Cause you physical harm
F29.
Sexually?
Force sexual advances or sexual acts
In her life, or past 30 days, not just during childhood.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___
______________________________________________________
___
___
______________________________________________________
___
___
______________________________________________________
F29b. Have you ever been hit by a sexual partner?
0 - No
1 - Yes
___
F29c. Have you ever been beaten while pregnant?
0 - No
1 - Yes
___
ADAI Sound Data Source—11/7/2006
______________________________________________________
___
F29a. Are you currently in what you consider to be an
___
abusive relationship with your partner?
0 - No
3 - Yes, sexual
1 - Yes, physical
4 - Yes, combination
2 - Yes, psychological
Page 16
______________________________________________________
______________________________________________________
Serious problems=those that endanger relationship. “Problem” requires
contact of some sort. If client has had no contact in past 30 days, code -8.
Did anybody ever abuse you:
0 - No
1 - Yes, once or twice
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY/SOCIAL RELATIONSHIPS (cont)
FAMILY/SOCIAL COMMENTS
(Include the question number with your notes)
How many days in the past 30 have you had serious conflicts:
F30.
with your family?
___ ___
F31.
with other people? (excluding family)
___ ___
For Questions F32 - F35, ask client to use the Client’s Rating Scale
______________________________________________________
______________________________________________________
How troubled or bothered have you been in the past 30 days by
these:
______________________________________________________
______________________________________________________
F32.
Family problems
___
F33.
Social problems
___
How important to you now is treatment or counseling for these:
F34.
Family problems
___
F35.
Social problems
___
______________________________________________________
______________________________________________________
______________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
F37.
Client’s misrepresentation?
0 - No
1 - Yes
___
______________________________________________________
F38.
Client’s inability to understand?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
INTERVIEWER CLIENT NEED RATING
F99a. How would you rate this client’s need for family and/
or social counseling?
___
0 - No need.
1 - Problems, but client currently connected with adequate services.
______________________________________________________
2 - Need for more counseling in addition to client’s current
counseling (if any).
______________________________________________________
3 - Urgent need for more family/social counseling/intervention in
addition to client’s current connection to services. Should be an
advocate priority.
______________________________________________________
___
______________________________________________________
F99b. How would you rate the client’s need for domestic
violence services?
0 - No domestic violence, no need.
1 - Domestic violence problem, but currently stable with services.
2 - Need for more domestic violence services, in addition to client’s
current services (if any).
3 - Dangerous domestic violence situation. Urgent need. Should
be an advocate priority.
ADAI Sound Data Source—11/7/2006
Page 17
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
PSYCHIATRIC STATUS
PSYCHIATRIC STATUS COMMENTS
How many times have you been treated for any psychological or
emotional problems:
P1.
In a hospital?
___ ___
P2.
As an outpatient or private patient?
___ ___
(Include the question number with your notes)
______________________________________________________
______________________________________________________
Per episode, not # of visits or # of days. Note when/where in comments.
___
P2a. Have you ever had a psychiatric evaluation?
0 - No
1 - Yes
Note reason for evaluation in comments.
______________________________________________________
___
P2b. If so, evaluation results:
0 - No diagnosis
1 - One diagnosis
2 - More than one diagnosis
-7 - Client doesn’t know her diagnosis
-8 - Client refuses to say, or N/A-hasn’t had an evaluation
P2c. List DSM-IV diagnosis(es) using 3-digit code from manual:
______________________________________________________
______________________________________________________
______________________________________________________
If never an evaluation, or client had evaluation but no diagnosis, code -8s.
Diagnosis 1: ________________________
___ ___ ___
Diagnosis 2: ________________________
___ ___ ___
Diagnosis 3: ________________________
Diagnosis 4: ________________________
___ ___ ___
___ ___ ___
Do not code FAS/FAE diagnosis here, code as Medical Diagnosis in M3.
P3.
______________________________________________________
Do you receive a pension for a psychiatric disability?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
From whom: ________________________________
______________________________________________________
Direction for P4-P11:
“In your life” refers to the entire lifetime period prior
to the past 30 days. Interviewer: ask lifetime question
from each pair first, then, regardless of answer,
inquire about past 30 days.
Items P4, P5, P6, P7: Be sure symptoms are
psychiatric in nature, i.e., NOT drug related.
______________________________________________________
______________________________________________________
______________________________________________________
P4.
Have you had a significant period (that was not a direct result of
drug/alcohol use) in which you have:
Past 30 Days In Your Life
0 - No
1 - Yes
Experienced serious depression
___
___
Sadness, hopelessness, loss of interest, difficulty
functioning, “crying jags.” (>2 wk period)
P5.
P6.
Experienced trouble understanding,
concentrating or remembering
Serious trouble, suggestive of cognitive problems.
(>2 wk period)
P8.
___
___
______________________________________________________
Experienced hallucinations
“Saw or heard things.” Not related to alc/drugs, can
be flashbacks. (Even once)
P7.
Experienced trouble controlling violent
behavior
___
___
___
___
___
___
___
___
Experienced serious thoughts of suicide
i.e., had a plan; can be drug/alc related. (Even
once)
When last? ________________________
P10. Attempted suicide
Can be drug/alc related. (Even once)
______________________________________________________
______________________________________________________
______________________________________________________
Can be drug/alc related. (Even once)
P9.
______________________________________________________
______________________________________________________
Experienced serious anxiety or tension
Unreasonably worried, unable to relax, feeling
uptight. (>2 wk period)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___
___
___
___
______________________________________________________
When last? ________________________
P11. Been prescribed medication for any
psychological/emotional problem
______________________________________________________
Whether or not she actually took the meds.
ADAI Sound Data Source—11/7/2006
Page 18
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
PSYCHIATRIC STATUS (cont)
PSYCHIATRIC STATUS COMMENTS
P12. How many days in the past 30 have you experienced
these psychological or emotional problems?
___ ___
(Include the question number with your notes)
______________________________________________________
Refers to problems listed in P4-P10.
For Questions P13 & P14, ask client to use the Client’s Rating Scale
______________________________________________________
___
P13. How much have you been troubled or bothered by
these psychological or emotional problems in the
past 30 days?
______________________________________________________
Referring to P12.
___
P14. How important to you now is treatment for these
psychological problems?
______________________________________________________
______________________________________________________
The following items are to be completed by the interviewer
At the time of the interview, is client:
0 - No
______________________________________________________
1 - Yes
P15. Obviously depressed/withdrawn
___
P16. Obviously hostile
___
P17. Obviously anxious/nervous
___
P18. Having trouble with reality testing, thought disorders,
paranoid thinking
___
______________________________________________________
P19. Having trouble comprehending, concentrating,
remembering
___
______________________________________________________
P20. Having suicidal thoughts
___
______________________________________________________
CONFIDENCE RATINGS
______________________________________________________
______________________________________________________
______________________________________________________
Is the above information significantly distorted by:
P22. Client’s misrepresentation?
0 - No
1 - Yes
P23. Client’s inability to understand?
0 - No
1 - Yes
INTERVIEWER CLIENT NEED RATING
P99. How would you rate this client’s need for psychiatric/
psychological treatment?
___
______________________________________________________
___
______________________________________________________
___
0 - No psychological problems, no need.
______________________________________________________
______________________________________________________
1 - Psychological problems, but current treatment has brought
condition to a controlled, non-problematic state.
______________________________________________________
2 - Need for more treatment in addition to client’s current treatment,
but not apparently dangerous or greatly interfering with client’s life.
______________________________________________________
3 - Urgent need for more treatment in addition to client’s current
treatment. Should be an advocate priority.
ADAI Sound Data Source—11/7/2006
Page 19
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY PLANNING & OTHER CHILDREN
FP1.
FP2.
Around the time of conception, did you normally use
some method of birth control?
0 - No
1 - Yes, regular use
2 - Yes, sporadic use
What method(s) did you use?
01 - Condoms
06 - Abortion
02 - Pills
07 - Abstinence
03 - Norplant
08 - Diaphragm
04 - Depo shot
09 - IUD
05 - Tubal ligation
10 - Other
Other, specify: _________________________
FAMILY PLANNING & OTHER CHILDREN COMMENTS
___
(Include the question number with your notes)
______________________________________________________
___ ___
___ ___
___ ___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
00 = no method or no further method
FP2a. Current method: _______________________________________
______________________________________________________
If currently pregnant, write N/A
___
FP3.
If you use condoms, do you use them every time,
with every sexual partner?
0 - No
1 - Yes
-8 = Never use
FP4.
Not including Target Child (TC), total # of biological
children who live with you now:
___ ___
1. ___ ___
2. ___ ___
3. ___ ___
4. ___ ___
5. ___ ___
6. ___ ___
FP4a. Not including Target Child (TC), ages of
all biological children who live with you
now:
00 = no children or no more children
______________________________________________________
Code from youngest to oldest. Code any infant’s age as 01. Do not code
target child here. If more than 6 children with mom, list ages of other children
here:
______________________________________________________________
FP5.
Not including Target Child (TC), total # of biological
children who DO NOT live with you now:
___ ___
1. ___ ___
2. ___ ___
3. ___ ___
4. ___ ___
5. ___ ___
6. ___ ___
FP5a. Not including Target Child (TC), ages of
all biological children who DO NOT live
with you now:
00 = no children or no more children
______________________________________________________
Code from youngest to oldest. Code any infant’s age as 01. Do not code
target child here. If more than 6 children not with mom, list ages of other
children here:
______________________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
CONFIDENCE RATINGS
______________________________________________________
Is the above information significantly distorted by:
FP6.
Client’s misrepresentation?
0 - No
1 - Yes
___
FP7.
Client’s inability to understand?
0 - No
1 - Yes
___
INTERVIEWER CLIENT NEED RATING
FP99. How would you rate the client’s need for family
planning services?
0-
Uses reliable method regularly or has tubal ligation, no need.
1-
Need for family planning, but currently pregnant.
2-
Need for family planning services. Uses birth control, but less
reliable method or practice.
3-
Urgent need for family planning. Should be an advocate priority.
ADAI Sound Data Source—11/7/2006
Page 20
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
COMMUNITY SERVICES
COMMUNITY SERVICES COMMENTS
Have you used this service during the last year or now?
How is this service working for you? (or your child(ren) or family,
depending on item)
• Code whether or not client or her children, as specified in the item, received this
service during the past year in the “Service Used” column. Code the quality of the
service received in the “Connection with Service” column, using prompts to focus on
how regular or adequate the connection, and her access to service, not on how well
the woman is doing. For example, the connection for AA group would be rated “1Good” if the woman attended regularly, even if she was still drinking.
• Note names of specific services or providers. Give enough information to be useful
in tracing.
• If the service was not needed, code -8 in the Service Used and Connection
columns.
Direction for S1-S17:
Service Used
Codes
0 - No, but needed
1 - Yes
3 - On waiting list
-8 - Not needed, N/A
S1.
Connection with
Service Codes
1 - Good
2 - Acceptable
3 - Poor
4 - Good/acceptable, but
problem with access
-8 - N/A
A.
Service Used?
B.
Connection With
Service
___
___
___
___
Regular health care provider or clinic for client
Who/Where: _______________________
S1a. Regular health care provider or clinic for child(ren)
S2.
What/Where: ______________________
S2a. Other healthcare services - for child(ren)
Physical therapy, dentist, eye doctor, etc.
___
___
___
___
What/Where: ______________________
#
appropriate
#
inappropriate
S2b. Client
___
___
S2c. Client’s child(ren)
___
___
Code # of visits of each type
If more than 6, code 6
What/Where: ________________________
Appropriate use = true medical emergency. Inappropriate use = healthcare that
should have been provided at a clinic or through a primary care provider.
B.
A.
Connection With
Service Used?
Service
At clinic, Planned Parenthood, etc.
S4.
S5.
Who/Where: _______________________
Alcoholics Anonymous or Narcotics
Anonymous (or other alcohol/drug peer
support group)
Group/Sponsor: ____________________
Other support group
Social, church group
S6.
What/Where: ______________________
Mental health service (client)
Diagnosis or counseling
What/Where: ______________________
ADAI Sound Data Source—11/7/2006
Page 21
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Emergency Room (E.R.) visits in past year
Family planning, birth control
______________________________________________________
______________________________________________________
Who/Where: _______________________
Other healthcare services - for client
Physical therapy, dentist, eye doctor, etc.
S3.
(Include the question number with your notes)
___
___
___
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___
___
___
___
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
COMMUNITY SERVICES (cont)
COMMUNITY SERVICES COMMENTS
Have you used this service during the last year or now?
How is this service working for you? (or your child(ren) or family,
depending on item)
Service Used
Codes
0 - No, but needed
1 - Yes
3 - On waiting list
-8 - Not needed, N/A
Connection with
Service Codes
1 - Good
2 - Acceptable
3 - Poor
4 - Good/acceptable, but
problem with access
-8 - N/A
B.
A.
Connection With
Service Used?
Service
S7.
Public housing
Section 8, low income
S8.
Specify: __________________________
Emergency housing
Include shelters
S9.
Specify: __________________________
Emergency funds for rent deposits, gas
vouchers, etc. OR Emergency bill
paying service
___
___
___
___
S10.
Salvation Army, Volunteers of America, etc.
S11.
Specify: __________________________
Food Bank
Or other food program, NOT food stamps
S12.
___
___
S13.
S14.
S15.
What/Where: ______________________
Daycare/childcare services
S16.
Specify: __________________________
Public Health Nurse
Home visits
S17.
___
___
___
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___
___
______________________________________________________
______________________________________________________
___
___
______________________________________________________
______________________________________________________
___
___
___
___
______________________________________________________
______________________________________________________
______________________________________________________
___
___
___
___
Specify: __________________________
Other
YMCA, Boys and Girls Club, Family Support
Center or other community resource center,
Home Builders Program, School Family Support
Worker, Big Brother/Big Sister Program, etc.
______________________________________________________
______________________________________________________
What/Where: ______________________
Public Schools
For extra services or problems, e.g., counseling,
truancy, child behavior issues, etc.
______________________________________________________
______________________________________________________
What/Where: ______________________
Domestic violence services
Crisis line, temporary shelter, protection/
restraining orders
______________________________________________________
______________________________________________________
What/Where: ______________________
Legal
Court, public defender, prosecutor, probation,
legal clinics. (If client has been in litigation or
resolved charges, warrants, etc., code 1)
______________________________________________________
______________________________________________________
Volunteers of America, St. Vincent, American Red
Cross, Salvation Army, etc. Include special
payment programs offered by utility, phone
companies, etc.
Specify: __________________________
Clothing/supplies
(Include the question number with your notes)
______________________________________________________
______________________________________________________
______________________________________________________
What/Where: ______________________
ADAI Sound Data Source—11/7/2006
Page 22
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
COMMUNITY SERVICES (cont)
COMMUNITY SERVICES COMMENTS
(Include the question number with your notes)
For questions S18-S24, code 0 - No, 1 - Yes
S18.
S19.
Are you currently receiving medical coupons or
Medicaid?
___
______________________________________________________
Do you have a private source of medical insurance?
___
______________________________________________________
Through work, partner’s work, etc.
Specify: ______________________________
______________________________________________________
S20.
Are you currently receiving food stamps?
___
S21.
Are you currently enrolled in the WIC program?
___
S22.
Have you had an open case with CPS (Child
Protective Services) in the last 3 years?
___
______________________________________________________
______________________________________________________
For your own children, not the children of someone else.
S23.
S24.
___
Have you taken a parenting class in the last year?
___
______________________________________________________
___
______________________________________________________
___
______________________________________________________
At clinic, as part of treatment, co-ops.
S24a. Was this mandated?
0 - No
1 - Yes
If S24 is No, then code -8
S24b. Did you complete the course?
0 - No
1 - Completed
2 - In progress
If S24 is No, then code -8
S25.
___
Are you in school/training now?
0 - No
4 - GED program
1 - High school
5 - Community college
2 - Trade/vocational program
3 - College/university (4 yr)
6 - Back-to-work program
7 - Other
S25a. Have you been involved in any (other) schooling in
past 3 years?
Code types from S25 above, whether or not completed.
S25b. Which of these programs have you completed (or are
currently in progress)
Code types from S25 above.
All programs coded here should also be coded in S25a.
______________________________________________________
______________________________________________________
1. ___
2. ___
3. ___
2. ___
______________________________________________________
______________________________________________________
Client’s misrepresentation?
0 - No
1 - Yes
___
S27.
Client’s inability to understand?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
COMMENTS ON VALIDITY:
COMPLETE AFTER CLIENT LEAVES
Anyone else present during interview?
0 - No
1 - Yes
___
Who? ______________________________
______________________________________________________
______________________________________________________
___
3 - Somewhat cooperative
4 - Very cooperative
______________________________________________________
V3.
Client under influence?
0 - No
1 - Yes, appeared so
2 - May have been, uncertain
___
V4.
Special (for part A only)
1 - Usual, one session interview
2 - Interrupted, multi-session
___
ADAI Sound Data Source—11/7/2006
Page 23
______________________________________________________
3. ___
S26.
Client cooperation
1 - Very uncooperative
2 - Somewhat uncooperative
______________________________________________________
1. ___
CONFIDENCE RATINGS
Is the above information significantly distorted by:
V2.
______________________________________________________
______________________________________________________
Specify other: _________________________
V1.
______________________________________________________
Do you have an open CPS case now?
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
Interviewer Comments on Interview/Client/Situation
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
PROFILE OF CLIENT NEED BASED ON
INTERVIEWER’S SUBJECTIVE ASSESSMENT
Codes here should match those in interview.
No
Problem/Issue
Problems
0
Problem/Issue
Problem/Issue
Problem/Issue
But currently
stable with
current services
Unaddressed
need, but not
urgent
Has urgent,
immediate
need
Lower priority
High priority
2
3
1
MEDICAL
EMPL/SUPP
ALCOHOL
DRUG
LEGAL
FAM/SOC
DOM VIOL
PSYCH
FAM PLAN
OTHER
Specify Other: _____________________________________________
ADAI Sound Data Source—11/7/2006
Page 24
Parent-Child Assistance Program (PCAP)
| File Type | application/pdf |
| File Title | 2 ASIIntakeA.pub |
| Author | ShradLa |
| File Modified | 2009-07-13 |
| File Created | 2009-07-13 |