Form CSAT Instrument CSAT Instrument CSAT Instrument

ATTACHMENT 6

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX

Client-Level Services

Measures for

Discretionary Programs

CSAT PROGRAM ONLY

Public reporting burden for this collection of information is estimated to average 28 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information, if all items are asked of a client/participant; to the extent that providers already obtain much of this information as part of their ongoing client baseline or reassessment, less time will be required. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 2-, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-xxxx.

A1: RECORD MANAGEMENT

THIS SECTION TO BE COMPLETED BY STAFF ONLY

SAMHSA Center:

� CSAT � CMHS � CSAP

Client ID |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|

Program Type:

� Treatment Grant Program

� Recovery Grant Program

Contract/Grant ID |____|____|____|____|____|____|____|____|____|____|

_____________________________________________________________________________________

1. Interview Type (SELECT ONLY ONE TYPE)

� Baseline

� Reassessment: Three-month follow-up (ADOLESCENT PORTFOLIO ONLY)

� Reassessment: |____|____| months (e.g., enter 06 for six months; enter 12 for one year)

� Discharge: Client completed services

� Discharge: Administrative (SKIP TO SECTION J)

2a. Was the interview conducted?

� Yes

� No (SKIP TO QUESTION 3A)

2b. If an interview was conducted, when did it take place?

Interview Date |____|____| / |____|____| / |____|____|____|____|

Month Day Year

_____________________________________________________________________________________

3a. Was the client screened by your program for co-occurring mental health and substance use

disorders?

� Yes

� No (SKIP TO QUESTION 4A)

3b. If the client was screened for co-occurring disorders, did the client screen positive for co-

occurring mental health and substance use disorders?

� Yes

� No

_____________________________________________________________________________________

A1: RECORD MANAGEMENT (CONT.)

4a. Was this an SBIRT grant?

� Yes

� No (SKIP TO SECTION A2)

THIS SECTION IS FOR SBIRT GRANTS REPORTED AT BASELINE ONLY. ALL OTHER GRANTEES CONTINUE TO SECTION A2.

4b. How did the client screen for your SBIRT?

� Negative

� Positive

4c. What was his/her screening score?

AUDIT = |____|____|

CAGE = |____|____|

DAST = |____|____|

DAST-10 = |____|____|

NIAAA Guide = |____|____|

ASSIST/Alcohol Subscore = |____|____|

Other (Specify) = |____|____|

______________________________________

______________________________________

______________________________________

4d. Was he/she willing to continue his/her participation in the SBIRT program?

� Yes

� No

BASELINE INTERVIEW, CONTINUE TO SECTION A2

REASSESSMENT AND DISCHARGE INTERVIEWS, SKIP TO SECTION B

End of A1: Record Management

SECTION A2

RECORD MANAGEMENT—PLANNED SERVICES

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

What services do you plan to provide to the client during the client’s course of treatment/recovery?

1. Modality

(CIRCLE AT LEAST ONE MODALITY)

a. Case management Yes No

b. Day treatment Yes No

c. Inpatient/Hospital Yes No

(Other than detox)

d. Outpatient Yes No

e. Outreach Yes No

f. Intensive outpatient Yes No

g. Medication assisted treatment

(CIRCLE ONLY ONE) For Opioid Addiction

(1) Methadone Yes No

(2) Buprenorphine Yes No

(3) Naltrexone ® (Oral) Yes No

(4) Vivitrol ® (Injectable) Yes No

(5) Disulfiram ® Yes No

(6) Acamprosate ® Yes No

For Alcohol Addiction

(1) Naltrexone ® (Oral) Yes No

(2) Vivitrol ® (Injectable) Yes No

(3) Disulfiram ® Yes No

(4) Acamprosate ® Yes No

h. Residential/Rehabilitation Yes No

i. Detoxification (CIRCLE ONLY ONE) (1) Hospital inpatient Yes No

(2) Free standing residential Yes No

(3) Ambulatory detoxification Yes No

j. After care Yes No

k. Recovery support Yes No

l. Other Yes No

(SPECIFY): _________________________

2. Treatment Services (CIRCLE AT LEAST ONE SERVICE)

a. Screening Yes No

b. Brief intervention Yes No

c. Brief treatment Yes No

d. Referral to treatment Yes No

e. Assessment Yes No

f. Treatment/Recovery planning Yes No

g. Individual counseling Yes No

h. Group counseling Yes No

i. Family/Marriage counseling Yes No

j. Co-occurring treatment/

Recovery services Yes No

k. Psycho-Pharmacological

interventions Yes No

l. HIV/AIDS counseling Yes No

m. Mental health services Yes No

n. Other clinical services Yes No

(SPECIFY): ______________________

3. Medical Services

(CIRCLE AT LEAST ONE SERVICE)

a. Medical care Yes No

b. Alcohol/drug testing Yes No

c. HIV/AIDS medical support & testing Yes No

d. Other medical services Yes No

(SPECIFY): ______________________

SECTION A2

RECORD MANAGEMENT—PLANNED SERVICES (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

4. Case Management Services

(CIRCLE AT LEAST ONE SERVICE)

1. Family services (Including marriage

education, parenting, child

development services) Yes No

b. Child care Yes No

c. Employment service

(1) Pre-employment Yes No

(2) Employment coaching Yes No

d. Individual services coordination Yes No

e. Transportation Yes No

f. HIV/AIDS service Yes No

g. Supportive transitional drug-free

housing services Yes No

h. Care coordination Yes No

i. Other case management services Yes No

(SPECIFY): ___________________________

5. After Care Services

(CIRCLE AT LEAST ONE SERVICE)

a. Continuing care Yes No b. Relapse prevention Yes No

c. Recovery coaching Yes No

d. Self-help and support groups Yes No

e. Spiritual support Yes No

f. Other after care services Yes No

(SPECIFY): ____________________________

6. Education Services

(CIRCLE AT LEAST ONE SERVICE)

a. Substance abuse education Yes No

b. HIV/AIDS education Yes No

c. Other education services Yes No

(SPECIFY): ___________________________

7. Peer-To-Peer Recovery Support Services (CIRCLE AT LEAST ONE SERVICE)

a. Peer coaching or mentoring Yes No

b. Housing support Yes No

c. Alcohol-and drug-free social

activities Yes No

d. Information and referral Yes No

e. Other peer-to-peer recovery

support services Yes No

(SPECIFY): ___________________________

CONTINUE TO SECTION A3

End of Section A2: Record Management—Planned Services

SECTION A3

DEMOGRAPHICS

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. What is your date of birth? (MONTH AND YEAR MUST BE ENTERED. DAY IS OPTIONAL)

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

� Declined

� Don’t know / Information not available

2. Are you Hispanic, Latino/a, or Spanish origin? (ONE OR MORE CATEGORIES MAY BE SELECT)

� Yes, Central American

� Yes, Cuban

� Yes, Dominican

� Yes, Mexican, Mexican American, Chicano/a

� Yes, Puerto Rican

� Yes, South American

� Yes, another Hispanic, Latino, or Spanish origin (SPECIFY): ___________________________

� No, not of Hispanic, Latino/a, or Spanish origin

� Declined

� Don’t know / Information not available

3. What is your race? (ONE OR MORE CATEGORIES MAY BE SELECT)

 White

 Black or African American

 American Indian

 Alaska Native

 Native Hawaiian

 Guamanian or Chamorro

 Samoan

 Other Pacific Islander

 Asian Indian

 Chinese

 Filipino

 Japanese

 Korean

 Vietnamese

 Other Asian

� Declined

� Don’t know / Information not available

4a. (ONLY FOR CLIENTS 5 YEARS OF AGE OR OLDER) Do you speak a language other than

English at home?

� Yes

� No (SKIP TO QUESTION 5)

� Declined (SKIP TO QUESTION 5)

� Don’t know / Information not available (SKIP TO QUESTION 5)

SECTION A3

DEMOGRAPHICS (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

4b. If you speak a language other than English at home, what language do you speak?

� Spanish

� Other (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

5. (ONLY FOR CLIENTS 5 YEARS OF AGE OR OLDER) What is your gender?

� Male

� Female

� Different identity (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

6. (ONLY FOR CLIENTS 12 YEARS OF AGE OR OLDER) Which one of the following do you

consider yourself to be?

� Straight

� Lesbian (if female) or Gay (if male)

� Bisexual

� Other (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

7. (ONLY FOR CLIENTS 12 YEARS OF AGE OR OLDER) In the past 12 months, who have you had sex with?

� Men only

� Women only

� Both men and women

� I have not had sex in the past 12 months

� Declined

� Don’t know / Information not available

� Not permitted to ask

SECTION A3

DEMOGRAPHICS (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

8. (ONLY FOR CLIENTS 12 YEARS OF AGE OR OLDER) Which statement best describes your

feelings?

[IF MALE] [IF FEMALE]

� I am only attracted to females � I am only attracted to males

� I am mostly attracted to females � I am mostly attracted to males

� I am equally attracted to females and males � I am equally attracted to males and females

� I am mostly attracted to males � I am mostly attracted to females

� I am only attracted to males � I am only attracted to females

� I am not sure � I am not sure

� Declined � Declined

� Don’t know / Information not available � Don’t know / Information not available

___________________________________________________________________________________

DISABILITY MEASURES

9. Are you deaf or do you have serious difficulty hearing?

� Yes

� No

� Declined

� Don’t know / Information not available

10. Are you blind or do you have serious difficulty seeing, even when wearing glasses?

� Yes

� No

� Declined

� Don’t know / Information not available

11. Have you been diagnosed with a learning disability (Autism, Dyslexia, ADHD, etc.)?

� Yes

� No

� Declined

� Don’t know / Information not available

12. Have you been diagnosed with a traumatic brain injury (TBI)?

� Yes

� No

� Declined

� Don’t know / Information not available

SECTION A3

DEMOGRAPHICS (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

13. (ONLY FOR CLIENTS 5 YEARS OR OLDER) Because of a physical, mental, or emotional

condition, do you have serious difficulty concentrating, remembering, or making decisions?

� Yes

� No

� Declined

� Don’t know / Information not available

14. (ONLY FOR CLIENTS 5 YEARS OR OLDER) Do you have serious difficulty walking or

climbing stairs?

� Yes

� No

� Declined

� Don’t know / Information not available

15. (ONLY FOR CLIENTS 5 YEARS OR OLDER) Do you have difficulty dressing or bathing?

� Yes

� No

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION A4

End of Section A3: Demographics

SECTION A4

MILITARY FAMILY AND DEPLOYMENT

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

QUESTIONS 1A-1E SHOULD ONLY BE ANSWERED IF CLIENT IS 17 YEARS OF AGE OR OLDER. IF CLIENT IS NOT 17 YEARS OF AGE OR OLDER, SKIP TO QUESTION 2A.

1a. Have you ever served on active, reserve, or National Guard duty?

� Yes

� No (SKIP TO QUESTION 2A)

� Declined (SKIP TO QUESTION 2A)

� Don’t know / Information not available (SKIP TO QUESTION 2A)

1b. If you ever served on active, reserve, or National Guard duty, in what branch of the military/uniformed services did you serve?

� Army

� Marine Corps

� Navy

� Air Force

� Coast Guard

� PHS

� NOAA

� Declined

� Don’t know / Information not available

1c. If you ever served on active, reserve, or National Guard duty, in which component did you serve?

� Active

� Reserve

� National Guard

� Declined

� Don’t know / Information not available

1d. If you ever served on active, reserve, or National Guard duty, are you currently on active duty or are you separated or retired?

� On active duty

� Separated

� Retired

� Declined

� Don’t know / Information not available

SECTION A4

MILITARY FAMILY AND DEPLOYMENT (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

1e. If you ever served on active, reserve, or National Guard duty, have you ever been deployed to a combat zone? (SELECT ALL THAT APPLY)

� No, never deployed to a combat zone

� Yes, Iraq or Afghanistan (e.g., OEF/OIF/OND)

� Yes, Persian Gulf (Operation Desert Shield/Desert Storm)

� Yes, Vietnam/Southeast Asia

� Yes, Korea

� Yes, Persian Gulf (Operation Desert Shield/Desert Storm)

� Yes, World War II

� Yes, other (SPECIFY COMBAT ZONE): __________________________________

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

For the following questions, immediate family includes your spouse or partner, and your parents, children, brothers and sisters, whether they are biological, step, or adoptive.  Please include these family members whether or not they live with you.

2a. Is anyone in your immediate family currently serving as a member of one the branches of the

United States Uniformed Services on active duty, reserve components or National Guard?

� Yes

� No (SKIP TO SECTION B)

� Declined (SKIP TO SECTION B)

� Don’t know / Information not available (SKIP TO SECTION B)

SECTION A4

MILITARY FAMILY AND DEPLOYMENT (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT BASELINE

2b. The following four questions relate to experiences you or a member of your immediate family may have had while serving?

	What is the relationship of that person (Service Member) to you: (IDENTIFY UP TO FIVE RELATIVES IN THE COLUMN HEADINGS. FOR EXAMPLE: MOTHER, FATHER, SISTER, BROTHER, SPOUSE, PARTNER, DAUGHTER, SON, OR OTHER IMMEDIATE RELATIVE).
Has the Service Member experienced any of the following:	(SELF)	Relationship (Specify): ___________	Relationship (Specify): ___________	Relationship (Specify): ___________	Relationship (Specify): ___________	Relationship (Specify): ___________
(1) Deployed in support of combat operations (e.g., Iraq or Afghanistan)?	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know
(2) Was physically injured during combat operations?	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know
(3) Developed combat stress symptoms/ difficulties adjusting following deployment, including PTSD, depression, or suicidal thoughts?	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know
(4) Died or was killed?		� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know	� Yes � No � Declined � Don’t know

CONTINUE TO SECTION B

End of Section A4: MILITARY FAMILY AND DEPLOYMENT

SECTION B

DRUG AND ALCOHOL USE

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

Offender Reentry Program (ORP) grants should ask about drug use “in the past 30 days prior to incarceration” for questions B1 through B6e at baseline and the “past 30 days” at reassessment and discharge.

1. In the past 30 days, how many days have you used alcoholic beverages?

|____|____| days (IF ZERO, SKIP TO QUESTION 4)

� Declined

� Don’t know / Information not available

2. (IF MALE)

In the past 30 days, how many days have you used alcohol to intoxication? (DEFINE INTOXICATION AS FOUR OR MORE DRINKS IN A DAY) (NUMBER OF DAYS IN QUESTION 2 SHOULD BE EQUAL TO OR LESS THAN NUMBER OF DAYS IN QUESTION 1)

|____|____| days � Declined

� Don’t know / Information not available

(IF FEMALE)

In the past 30 days, how many days have you used alcohol to intoxication? (DEFINE INTOXICATION AS THREE OR MORE DRINKS IN A DAY) (NUMBER OF DAYS IN QUESTION 2 SHOULD BE EQUAL TO OR LESS THAN NUMBER OF DAYS IN QUESTION 1)

|____|____| days � Declined

� Don’t know / Information not available

3. (FOR MALES AND FEMALES) In the past 30 days, how many days have you used both alcohol and drugs (on the same day)? (NUMBER OF DAYS IN QUESTION 3 SHOULD BE EQUAL TO OR LESS THAN NUMBER OF DAYS IN QUESTION 1)

|____|____| days � Declined

� Don’t know / Information not available

_________________________________________________________________________________

4. In the past 30 days, how many days did you use any illegal drugs including prescription drugs

that were taken for reasons or in doses other than prescribed?

|____|____| days (IF ZERO, SKIP TO QUESTION 5I)

� Declined (SKIP TO QUESTION 5I)

� Don’t know / Information not available (SKIP TO QUESTION 5I)

SECTION B

DRUG AND ALCOHOL USE (CONT.)

5. The following ten questions (5a-5j) relate to your experience with drugs. Some may be

prescribed by a doctor (like pain medication), but I will only record those if you have taken them for reasons or in doses other than prescribed.

 If the value in any question 5a through 5h is more than zero, then the value in question 4 should be more than zero.

 "Route" refers to route of administration. Note the usual route. For more than one route, choose from the following options: (1) Oral, (2) Nasal, (3) Smoking, (4) Non-IV Injection, (5) IV

In the past 30 days, how many days have you used—

5a. Cocaine (coke, crack, etc.)? |____|____| days

� Declined |____| route

� Don’t know / Information not available

5b. Prescription stimulants (Ritalin, Concerta, |____|____| days

Dexedrine, Adderall, diet pills, etc.)? |____| route

� Declined

� Don’t know / Information not available

5c. Methamphetamine (speed, crystal meth, ice, etc.)? |____|____| days

� Declined |____| route

� Don’t know / Information not available

5d. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)? |____|____| days

� Declined |____| route

� Don’t know / Information not available

5e. Sedatives or sleeping pills (Valium, Serepax, Ativan, |____|____| days

Librium, Xanax, Rohypnol, GHB, etc.)? |____| route

� Declined

� Don’t know / Information not available

5f. Hallucinogens (LSD, acid, mushrooms, PCP, |____|____| days

Special K, ecstasy, etc.)? |____| route

� Declined

� Don’t know / Information not available

5g. Street opioids (heroin, opium, etc.)? |____|____| days

� Declined |____| route

� Don’t know / Information not available

5h. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], |____|____| days

hydrocodone [Vicodin], methadone, buprenorphine, etc.)? |____| route

� Declined

� Don’t know / Information not available

SECTION B

DRUG AND ALCOHOL USE (CONT.)

 If the value in any question 5a through 5h is more than zero, then the value in question 4 should be more than zero.

 "Route" refers to route of administration. Note the usual route. For more than one route, choose from the following options: (1) Oral, (2) Nasal, (3) Smoking, (4) Non-IV Injection, (5) IV

5i. Cannabis (marijuana, pot, grass, hash, etc.)? |____|____| days

� Declined |____| route

� Don’t know / Information not available

5j. Other? (SPECIFY): __________________________ |____|____| days

� Declined |____| route

� Don’t know / Information not available

_____________________________________________________________________________________

6. The following five questions (6a-6e) relate to your experience with tobacco or tobacco related products.

In the past 30 days, how many days have you used—

6a. Cigarettes? |____|____| days

� Declined

� Don’t know / Information not available

6b. Chewing tobacco? |____|____| days

� Declined

� Don’t know / Information not available

6c. Cigars? |____|____| days

� Declined

� Don’t know / Information not available

6d. Electronic Cigarettes (e-cigarettes)? |____|____| days

� Declined

� Don’t know / Information not available

6e. Other tobacco related products? |____|____| days

� Declined (SPECIFY): ______________________

� Don’t know / Information not available

CONTINUE TO SECTION C

End of Section B: Drug and Alcohol Use

SECTION C

FAMILY AND HOUSING

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. (DO NOT READ RESPONSE OPTIONS TO CLIENT) In the past 30 days, where have you been

living most of the time?

� Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway

station/airport or anywhere outside)

� Emergency shelter, including hotel or motel

� Staying or living with family/friends (e.g., room, apartment or house)

� Transition Housing

� Substance abuse treatment facility or detox center

� Residential treatment (substance abuse or mental health)

� Therapeutic community or hallway house

� Psychiatric hospital or other psychiatric facility

� Long-term care facility or nursing home

� Hospital or other residential non-psychiatric medical facility

� Permanent supportive housing

� Foster care home or foster care group home

� Jail, prison, or juvenile detention facility

� House rented by client

� House owned by client

� Other (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

2. In the past 30 days, how many nights have you been homeless?

|____|____| nights � Declined

� Don’t know / Information not available

3. During the past 30 days, how stressful have things been for you because of your use of alcohol or other drugs?

� Not at all

� Somewhat

� Considerably

� Extremely

� Declined

� Don’t know / Information not available

4. During the past 30 days, has your use of alcohol or other drugs caused you to reduce or give up important activities?

� Not at all

� Somewhat

� Considerably

� Extremely

� Declined

� Don’t know / Information not available

SECTION C

FAMILY AND HOUSING (CONT.)

5. During the past 30 days, has your use of alcohol or other drugs caused you to have emotional problems?

� Not at all

� Somewhat

� Considerably

� Extremely

� Declined

� Don’t know / Information not available

_________________________________________________________________________________

6. Are you currently pregnant?

� Yes

� No

� Declined

� Don’t know / Information not available

7a. (IF NOT MALE) Do you have any children?

� Yes

� No (SKIP TO SECTION D)

� Declined (SKIP TO SECTION D)

� Don’t know / Information not available (SKIP TO SECTION D)

7b. If you have any children, how many children do you have? (IF THE ANSWER TO QUESTION 7A IS YES, VALUE IN QUESTION 7B MUST BE GREATER THAN ZERO)

|____|____| children 

� Declined

� Don’t know / Information not available

7c. If you have any children, how many of your children are living with someone else due to a child protection court order? (THE VALUE IN QUESTION 7C CANNOT EXCEED THE VALUE IN QUESTION 7B)

|____|____| children 

� Declined

� Don’t know / Information not available

7d. If you have any children, for how many of your children have you lost parental rights? (THE CLIENT'S PARENTAL RIGHTS WERE TERMINATED) (THE VALUE IN QUESTION 7D CANNOT EXCEED THE VALUE IN QUESTION 7B)

|____|____| children 

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION D

End of Section C: Family and Housing

SECTION D

EDUCATION, EMPLOYMENT, AND INCOME

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. Are you currently enrolled in school or job training program? (IF INCARCERATED, SELECT “NO/NOT ENTROLLED”)

� No/Not enrolled

� Enrolled, full time

� Enrolled, part time

� Other (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

2. What is the highest level of education you have finished (whether or not you received a degree)?

 Preschool

 Kindergarten

 1st Grade

 2nd Grade

 3rd Grade

 4th Grade

 5th Grade

 6th Grade

 7th Grade

 8th Grade

 9th Grade

 10th Grade

 11th Grade

 12th Grade/High School Diploma/Equivalent

 Some college or university

 Bachelor's degree (BA, BS) or higher

 Vocational/Technical diploma after high school

 I never attended school or a job training program

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

SECTION D

EDUCATION, EMPLOYMENT, AND INCOME (CONT.)

3. Are you currently employed (IF INCARCERATED, SELECT UNEMPLOYED, NOT LOOKING FOR WORK)

 If client is under 16 years of age, skip to Section E.

 Clarify by focusing on status during most of the previous week, determining whether client worked at all or had a regular job but was off work.

 If client is ENROLLED, FULL TIME in question 1 and indicated EMPLOYED, FULL TIME in question 3, ask for clarification.

 If client is incarcerated and has no work outside of jail, code question 3 as UNEMPLOYED, NOT LOOKING FOR WORK.

� Employed full time (35+ hours per week, or would have been)

� Employed part time

� Unemployed, looking for work (SKIP TO QUESTION 7)

� Unemployed, disabled (SKIP TO QUESTION 7)

� Unemployed, volunteer work (SKIP TO QUESTION 7)

� Unemployed, retired (SKIP TO QUESTION 7)

� Unemployed, not looking for work (SKIP TO QUESTION 7)

� Other (SPECIFY): __________________________________

� Declined (SKIP TO QUESTION 7)

� Don’t know / Information not available (SKIP TO QUESTION 7)

4. Are you paid at or above the minimum wage?

� Yes

� No

� Declined

� Don’t know / Information not available

5. Are your wages paid directly to you by your employer?

� Yes

� No

� Declined

� Don’t know / Information not available

6. Could anyone have applied for your job?

� Yes

� No

� Declined

� Don’t know / Information not available

SECTION D

EDUCATION, EMPLOYMENT, AND INCOME (CONT.)

7. Approximately, how much money did you receive (pre-tax individual income) in the past 30 days from—

 If UNEMPLOYED, NOT LOOKING FOR WORK and value in question 7A is greater than zero, PROBE.

 If UNEMPLOYED, LOOKING FOR WORK and value in question 7B is zero, PROBE.

 If UNEMPLOYED, RETIRED and value in question 7C is zero, PROBE.

 If UNEMPLOYED, DISABLED and value in question 7D is zero, PROBE.

7a. Wages

$ |__|__|__| , |__|__|__|

� Declined

� Don’t know / Information not available

7b. Public assistance

$ |__|__|__| , |__|__|__|

� Declined

� Don’t know / Information not available

7c. Retirement

$ |__|__|__| , |__|__|__|

� Declined

� Don’t know / Information not available

7d. Disability

$ |__|__|__| , |__|__|__|

� Declined

� Don’t know / Information not available

7e. Non-legal income

$ |__|__|__| , |__|__|__|

� Declined

� Don’t know / Information not available

7f. Family and/or friends

$ |__|__|__| , |__|__|__|

� Declined

� Don’t know / Information not available

7g. Other (SPECIFY): ___________________

$ |__|__|__| , |__|__|__|

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION E

End of Section D: Education, Employment, and Income

SECTION E

CRIME AND CRIMINAL JUSTICE STATUS

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1a. In the past 30 days, how many times have you been arrested?

|____|____| times (IF ZERO, SKIP TO QUESTION 2)  

� Declined (SKIP TO QUESTION 2)

� Don’t know / Information not available (SKIP TO QUESTION 2)

1b. Out of the times you have been arrested in the past 30 days, how many times have you

been arrested for drug-related offenses? (VALUE IN QUESTION 1B CANNOT EXCEED VALUE IN QUESTION 1A)  

|____|____| times

� Declined

� Don’t know / Information not available

1c. Out of the times you have been arrested in the past 30 days, how many nights have you

spent in jail/prison? (If value in question 1A is greater than 15, section C, question 1 must be JAIL/PRISON. If question section C, question 1 is JAIL/PRISON, than value in question 1C must be at least 15.)

|____|____| nights

� Declined

� Don’t know / Information not available

Offender Reentry Program (ORP) grants please ask if a crime was committed “30 days prior to incarceration” at baseline and “the past 30 days’ at reassessment and discharge.

2. In the past 30 days, how many times have you committed a crime? (The answer to Question 2 must be equal to or greater than the number in section B, Question 4 because using illegal drugs is a crime)

|____|____| times

� Declined

� Don’t know / Information not available

3. Are you currently awaiting charges, trial, or sentencing?

� Yes

� No

� Declined

� Don’t know / Information not available

4. Are you currently on parole/probation?

� Yes

� No

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION F1

End of Section E: Crime and Criminal Justice Status

SECTION F1

MENTAL AND PHYSICAL HEALTH

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. How would you rate your overall health right now?

� Excellent

� Very Good

� Good

� Poor

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

2. During the past 30 nights, did you receive inpatient treatment for:

2a. Physical complaint

� Yes. SPECIFY number of nights: |____|____|

� No

� Declined

� Don’t know / Information not available

2b. Mental or emotional difficulties

� Yes. SPECIFY number of nights: |____|____|

� No

� Declined

� Don’t know / Information not available

2c. Alcohol or substance abuse

� Yes. SPECIFY number of nights: |____|____|

� No

� Declined

� Don’t know / Information not available

3. During the past 30 nights, did you receive outpatient treatment for:

3a. Physical complaint

� Yes. SPECIFY number of nights: |____|____|

� No

� Declined

� Don’t know / Information not available

SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)

3b. Mental or emotional difficulties

� Yes. SPECIFY number of nights: |____|____|

� No

� Declined

� Don’t know / Information not available

3c. Alcohol or substance abuse

� Yes. SPECIFY number of nights: |____|____|

� No

� Declined

� Don’t know / Information not available

4. During the past 30 nights, did you receive emergency room/urgent care treatment for:

4a. Physical complaint

� Yes. SPECIFY number of nights: |____|____|

� No

� Declined

� Don’t know / Information not available

4b. Mental or emotional difficulties

� Yes. SPECIFY number of nights: |____|____|

� No

� Declined

� Don’t know / Information not available

4c. Alcohol or substance abuse

� Yes. SPECIFY number of nights: |____|____|

� No

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

THE FOLLOWING THREE QUESTIONS (5-7) ARE ONLY FOR CLIENTS 10 YEARS OF AGE AND OLDER

5. (ONLY ASK AT BASELINE) Have you ever tried to kill yourself?

� Yes

� No

� Declined

� Don’t know / Information not available

SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)

6. (ASK AT REASSESSMENT AND DISCHARGE) At any time in the past 6 months (including

today), did you seriously think about trying to kill yourself?

� Yes

� No

QUESTIONS	RESPONSE OPTIONS
During the past 30 days, about how often did you feel—	All of the Time	Most of the Time	Some of the Time	A Little of the Time	None of the Time	Declined	Don't know/ Info not Available
8a. Nervous	�	�	�	�	�	�	�
8b. Hopeless	�	�	�	�	�	�	�
8c. Restless or fidgety	�	�	�	�	�	�	�
8d. So depressed that nothing could cheer you up	�	�	�	�	�	�	�
8e. That everything was an effort	�	�	�	�	�	�	�
8f. Worthless	�	�	�	�	�	�	�
8g. Bothered by the above psychological or emotional problems	�	�	�	�	�	�	�

� Declined

� Don’t know / Information not available

7. (ASK AT REASSESSMENT AND DISCHARGE) During the past 6 months (including today), did you try to kill yourself?

� Yes

� No

� Declined

� Don’t know / Information not available

_____________________________________________________________________________________

8. The following seven questions (8a-8g) ask about how you have been feeling during the past 30 days. For each question, please indicate how often you had this feeling.

SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)

9a. During the past 30 days, did you engage in sexual activity?

� Yes

� No (SKIP TO QUESTION 10A)

� Declined (SKIP TO QUESTION 10A)

� Don’t know / Information not available (SKIP TO QUESTION 10A)

� Not permitted to ask (SKIP TO QUESTION 10A)

9b. If you engaged in sexual activity in the past 30 days, altogether, did you engage in protected or unprotected—

	Yes, Protected	Yes, Unprotected	No	Declined	Don't know/ Information not available
(1) Vaginal sexual contacts	�	�	�	�	�
(2) Oral sexual contacts	�	�	�	�	�
(3) Anal sexual contacts	�	�	�	�	�

9c. If you engaged in sexual activity in the past 30 days, unprotected sexual contacts were with an individual who is or was:

	Yes	No	Declined	Don't know/ Information not available
(1) HIV positive or has AIDS	�	�	�	�
(2) An injection drug user	�	�	�	�
(3) High on some substance	�	�	�	�

_____________________________________________________________________________

10a. Have you been tested for HIV?

� Yes

� No (SKIP TO QUESTION 11A)

� Declined (SKIP TO QUESTION 11A)

� Don’t know / Information not available (SKIP TO QUESTION 11A)

SECTION F1

MENTAL AND PHYSICAL HEALTH (CONT.)

10b. If you have been tested for HIV, what was the result?

� Negative/Non-reactive

� Positive/reactive

� Invalid/Indeterminate

� Declined

� Don’t know / Information not available

11a. Have you been tested for Hepatitis B?

• Yes

• No (SKIP TO QUESTION 12A)

• Decline (SKIP TO QUESTION 12A)

• Don’t know (SKIP TO QUESTION 12A)

11b. If you have been tested for Hepatitis B, what was the result?

• Negative/Non-Reactive

• Positive/Reactive

• Invalid/Indeterminate

• Declined

• Don’t know/information not available

12a. Have you been tested for Hepatitis C?

• Yes

• No (SKIP TO SECTION F2)

• Decline (SKIP TO SECTION F2)

• Don’t know (SKIP TO SECTION F2)

12b. If you have been tested for Hepatitis C, what was the result?

• Negative/Non-Reactive

• Positive/Reactive

If Positive/Reactive, did you receive a confirmatory test?

• Yes

• No

• Invalid/Indeterminate

• Declined

• Don’t know/information not available

CONTINUE TO SECTION F2

End of Section F1: Mental and Physical Health

SECTION F2

RECOVERY, SELF-HELP, AND PEER-SUPPORT

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. In the past 30 days, have you attended any voluntary self-help groups for recovery that were not affiliated with a religious or faith-based organization?

In other words, did you participate in a non-professional, peer-operated organization that is devoted to helping individuals who have addiction related problems such as: Alcoholics Anonymous, Narcotics Anonymous, Oxford House, Secular Organization for Sobriety, or Women for Sobriety, etc.

� Yes. SPECIFY number of times: |____|____|

� No

� Declined

� Don’t know / Information not available

2. In the past 30 days have you attended any religious/faith affiliated recovery self-help groups?

� Yes. SPECIFY number of times: |____|____|

� No

� Declined

� Don’t know / Information not available

3. In the past 30 days, have you attended meetings of organizations that support recovery other

than religious/faith and non-religious faith self-help groups?

� Yes. SPECIFY number of times: |____|____|

� No

� Declined

� Don’t know / Information not available

4. In the past 30 days, have you had interaction with family and/or friends that are supportive of

your recovery?

� Yes

� No

� Declined

� Don’t know / Information not available

5. In the past 30 days, I generally accomplished what I set out to do.

� Strongly agree

� Agree

� Undecided

� Disagree

� Strongly disagree

� Declined

� Don’t know / Information not available

SECTION F2

RECOVERY, SELF-HELP, AND PEER-SUPPORT (CONT.)

6. I feel capable of managing my health care needs.

� On my own most of the time

� With support from others most of the time

� On my own

� Some of the time and with support from others

� Some of the time

� Rarely or never

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION F3

End of Section F2: Recovery, Self-Help, and Peer-Support

SECTION F3

VIOLENCE AND TRAUMA

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

THE FOLLOWING THREE QUESTIONS (1A-1C) TO BE COMPLETED AT BASELINE ONLY

1a. In your life have you ever experienced an event, series of events, or set of circumstances that

resulted in you feeling physically or emotionally harmed or threatened?

� Yes

� No (SKIP TO QUESTION 2)

� Declined (SKIP TO QUESTION 2)

� Don’t know / Information not available (SKIP TO QUESTION 2)

1b. If you ever experienced an event that resulted in you feeling physically or emotionally harmed or threatened, what kind of event was this? (SELECT ALL THAT APPLY)

� Natural or man-made disaster

� Community or school violence

� Interpersonal violence (including physical, sexual or psychological)

� Military trauma

� Other (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

1c. Did any of the above experiences feel so frightening, horrible, or upsetting that in the past and/or the present that you:

(1) Have had nightmares about them or thought about them when you did not want to?

� Yes

� No

� Declined

� Don’t know / Information not available

(2) Tried hard not to think about them or went out of your way to avoid situations that remind

you of them?

� Yes

� No

� Declined

� Don’t know / Information not available

(3) Were constantly on guard, watchful, or easily startled?

� Yes

� No

� Declined

� Don’t know / Information not available

SECTION F3

VIOLENCE AND TRAUMA (CONT.)

(4) Felt numb and detached from others, activities, or your surroundings?

� Yes

� No

� Declined

� Don’t know / Information not available

2. In the past 30 days, how often have you experienced an event, series of events, or set of circumstances that resulted in you feeling physically or emotionally harmed or threatened?

Never

A few times

More than a few times

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION G

End of Section F3: Violence and Trauma

SECTION G

SOCIAL CONNECTEDNESS

NOTE: THE FOLLOWING QUESTIONS ARE ADDRESSED TO THE CLIENT.

1. Please indicate your disagreement/agreement with each of the following statements. Please

answer for relationships with persons other than your mental health provider(s) over the past

30 days.

QUESTIONS	RESPONSE OPTIONS
Over the past 30 days—	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	Declined	Don't know/ Info not Available
1a. In a crisis, I would have the support I need from family or friends.	�	�	�	�	�	�	�
1b. I feel I belong in my community.	�	�	�	�	�	�	�

2. To whom do you turn when you are having trouble?

� No one

� Clergy member

� Family member

� Friends

� Other (SPECIFY): __________________________________

� Declined

� Don’t know / Information not available

CONTINUE TO SECTION H

End of Section G: Social Connectedness

SECTION H

PROGRAM SPECIFIC QUESTIONS

Some programs have program specific data. You will be informed if you are required to complete Section H, and you will have a separate Section H Form.

STOP HERE FOR BASELINE INTERVIEW

CONTINUE TO SECTION I FOR REASSESSMENT

SKIP TO SECTION J FOR DISCHARGE

End of Section H: Program Specific Questions

SECTION I

REASSESSMENT STATUS

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT REASSESSMENT

_____________________________________________________________________________

3a. Did the program test this client for HIV?

� Yes

� No (SKIP TO QUESTION 3C)

QUESTIONS	QUESTIONS
Over the past 30 days—	Yes	No
1. Have you or other grant staff had contact with the client within 90 days of the last encounter?	�	�
2. Is the client still receiving services from your program?	�	�

3b. If the client was tested for HIV, what was the result?

� Negative/Non-reactive (SKIP TO QUESTION 4A)

� Positive/Reactive (SKIP TO QUESTION 4A)

� Invalid/Indeterminate (SKIP TO QUESTION 4A)

3c. If the client was not tested for HIV, did the program refer this client for testing?

� Yes

� No

• Client Declined Testing

_____________________________________________________________________________

4a. Did the program test the client for Viral Hepatitis?

� Yes

� No (SKIP TO SECTION K)

4b. If the client was tested for Viral Hepatitis, did the client receive the test results? (CHECK ALL THAT APPLY)

Hepatitis B � Yes � No

Hepatitis C    � Yes � No

SECTION I

REASSESSMENT STATUS (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT REASSESSMENT

4c. If the client received the Viral Hepatitis test results, what were the results? (CHECK ALL THAT APPLY)

Hepatitis C                          

� Negative/Non-reactive

� Positive/Reactive

� Invalid/Indeterminate

� Not Applicable                       

5a. Did the program conduct a Confirmatory Hepatitis Test?

� Yes

� No (SKIP TO SECTION K)

5b. If the program conducted a Confirmatory Hepatitis test, did the client receive the results? (check all that apply)

Hepatitis B � Yes � No

Hepatitis C    � Yes � No

5c. If the client received the Confirmatory Hepatitis test results, what were the results?

	Negative/Non-reactive	Positive/Reactive	Invalid/Indeterminate	Not Applicable
Hepatitis B	�	�	�	�
Hepatitis C	�	�	�	�

SKIP TO SECTION K

End of Section I: Reassessment Status

SECTION J

DISCHARGE STATUS

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT DISCHARGE

1. On what date was the client discharged?

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

2. On what date did the client last receive services?

|____|____| / |____|____| / |____|____|____|____|

Month Day Year

3. What is the client’s discharge status?

� Mutually agreed cessation of treatment

� Withdrew from/Declined treatment

� No contact within 90 days of last encounter

� Incarcerated (NEWLY OR RE-INCARCERATED)

� Clinically referred out

� Death

� Other (SPECIFY): __________________________________

____________________________________________________________________________

4a. Did the program test this client for HIV?

� Yes

� No (SKIP TO QUESTION 4C)

4b. If the client was tested for HIV, what was the result?

� Negative/Non-reactive (SKIP TO QUESTION 5A)

� Positive/reactive (SKIP TO QUESTION 5A)

� Invalid/Indeterminate (SKIP TO QUESTION 5A)

4c. If the client was not tested for HIV, did the program refer this client for testing?

� Yes

� No

• Client Declined Testing

____________________________________________________________________________

5a. Did the program test the client for Viral Hepatitis?

� Yes

� No (SKIP TO SECTION K)

SECTION I

REASSESSMENT STATUS (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY AT REASSESSMENT

5b. If the client was tested for Viral Hepatitis, did the client receive the test results? (CHECK ALL THAT APPLY)

Hepatitis B � Yes � No

Hepatitis C    � Yes � No

5c. If the client received the Viral Hepatitis test results, what were the results? (CHECK ALL THAT APPLY)

Hepatitis C                          

� Negative/Non-reactive

� Positive/Reactive

� Invalid/Indeterminate

� Not Applicable                       

6a. Did the program conduct a Confirmatory Hepatitis Test?

� Yes

� No (SKIP TO SECTION K)

6b. If the program conducted a Confirmatory Hepatitis test, did the client receive the results? (check all that apply)

Hepatitis B � Yes � No

Hepatitis C    � Yes � No

6c. If the client received the Confirmatory Hepatitis test results, what were the results?

	Negative/Non-reactive	Positive/Reactive	Invalid/Indeterminate	Not Applicable
Hepatitis B	�	�	�	�
Hepatitis C	�	�	�	�

CONTINUE TO SECTION K

End of Section J: Discharge Status

SECTION K

PREGNANT AND POSTPARTUM WOMEN (PPW)

THIS SECTION TO BE COMPLETED BY STAFF ONLY

THIS SECTION FOR PPW GRANTEES ONLY

The following direct services are required either under Section 508 of the Public Health Service Act, as amended or by SAMHSA, and are deemed necessary for comprehensive substance abuse prevention, treatment, and recovery support services system for women, their  minor  children, age 17 and under, and other family members.  These services can be provided either by the applicant or through MOUs/MOAs with partners in the network.

SELECT ALL THAT APPLY

1. Women

 Outreach, engagement, pre-treatment, screening, and assessment

 Detoxification, Medical Assisted Treatment (SELECT ALL THAT APPLY)

For Opioid Addiction

• Methadone

• Buprenorphine

• Naltrexone (Oral)

• Vivitrol (Injectable)

• Disulfiram

• Acamprosate

For Alcohol Addiction

• Naltrexone (Oral)

• Vivitrol (Injectable)

• Disulfiram

• Acamprosate

 Substance abuse education, treatment, and relapse prevention

 Medical, dental, and other health care services, including obstetrics, gynecology,

diabetes, hypertension, and prenatal care

 Postpartum health care including attention to depression and anxiety disorders, and

medication needs

 Specialized assessment, monitoring, and referrals for education, peer support,

therapeutic interventions and physical safety

 Mental health care that includes a trauma-informed system of assessments and

interventions

 Parenting education and interventions

 Home management and life skills training

 Education, testing, counseling, and treatment of hepatitis, HIV/AIDS, other STDs,

and related issues;

 Employment readiness, and job training and placement

 Education and tutoring assistance for obtaining a high school diploma and beyond

 Childcare during periods in which the woman is engaged in therapy or in other

necessary health or rehabilitative activities

 Peer-to-peer recovery support activities such as groups, mentoring, and coaching

 Transportation and other necessary wraparound services

SECTION K

PREGNANT AND POSTPARTUM WOMEN (PPW) (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY

2. Children

 Screenings and developmental diagnostic assessments regarding the social,

emotional, cognitive, and physical status of the infants at birth through

developmental trajectories of the children

 Prevention assessments and interventions related to mental, emotional, and

behavioral wellness

 Mental health care that includes a trauma-informed system of assessments,

interventions, and social-emotional skill building services

 Developmental services and therapeutic interventions, including child care,
counseling, play and art therapy, occupational, speech and physical therapies

 Primary and pediatric health care services, including immunizations, and treatment for asthma, diabetes, hypertension, and any perinatal and environmental effects of maternal and/or paternal substance abuse, e.g., HIV, abuse, and neglect

 Social services, including financial supports and health care benefits; and

 Education and recreational services

3. Family

 Family-focused programs to support family strengthening and reunification,

including parenting education and interventions and social and recreational

activities

 Alcohol and drug education and referral services for substance abuse treatment

 Mental health promotion and assessment, prevention and treatment services, in a

trauma-informed context

 Social services, including home visiting, education, vocational, employment,

financial, and health care services

4. Case Management

 Coordination and integration of services, and support with navigating systems of

care to implement the individualized and family service plans

 Assess and monitor the extent to which required services are appropriate for

women, children, and the family members of the women and children

 Assistance with community reintegration, before and after discharge, including

referrals to appropriate services and resources

 Assistance in accessing resources from federal, state, and local programs that

provide a range of treatment services, including substance abuse, health, mental

health, housing, employment, education, and training

 Connections to safe, stable, and affordable housing that can be sustained over time

End of Section K: Pregnant and Postpartum Women

THIS SECTION TO BE COMPLETED BY STAFF.

ALL PROGRAMS EXCEPT PPW PROGRAMS SHOULD COMPLETE THIS SECTION.

Identify the number of DAYS of services or SESSIONS provided to the client during the client’s course of treatment/recovery. (ENTER ZERO IF NO SERVICES PROVIDED. YOU SHOULD HAVE AT LEAST ONE DAY FOR MODALITY)

SBIRT GRANTS: You must have at least one session for one of the Treatment Services numbered 2A through 2D.

1. Modality	Days		2. Treatment Services	Sessions
Case Management	|___|___|___|		a. Screening	|___|___|___|
Day Treatment	|___|___|___|		b. Brief Intervention	|___|___|___|
Inpatient/Hospital (Other Than Detox)	|___|___|___|		c. Brief Treatment	|___|___|___|
Outpatient	|___|___|___|		d. Referral to Treatment	|___|___|___|
Outreach	|___|___|___|		e. Assessment	|___|___|___|
Intensive Outpatient	|___|___|___|		f. Treatment/Recovery
Medication Assisted Treatment			Planning	|___|___|___|
For Opioid Addiction			g. Individual Counseling	|___|___|___|
(1) Methadone	|___|___|___|		h. Group Counseling	|___|___|___|
(2) Buprenorphine	|___|___|___|		i. Family/Marriage
(3) Naltrexone ® (Oral)	|___|___|___|		Counseling	|___|___|___|
(4) Vivitrol ® (Injectable)	|___|___|___|		j. Co-Occurring Treatment/
(5) Disulfiram ®	|___|___|___|		Recovery Services	|___|___|___|
(6) Acamprosate ®	|___|___|___|		k. Psycho-Pharmacological
For Alcohol Addiction			Interventions	|___|___|___|
(1) Naltrexone ® (Oral)	|___|___|___|		l. HIV/AIDS Counseling	|___|___|___|
(2) Vivitrol ® (Injectable)	|___|___|___|		m. Mental health services	|___|___|___|
(3) Disulfiram ®	|___|___|___|		n. Other
(4) Acamprosate ®	|___|___|___|		(SPECIFY): ___________	|___|___|___|
h. Residential/Rehabilitation	|___|___|___|
i. Detoxification (SELECT ONLY ONE): (1) Hospital Inpatient			3. Medical Services
(2) Free Standing Residential	|___|___|___|		Medical Care	|___|___|___|
(3) Ambulatory Detoxification	|___|___|___|		Alcohol/Drug Testing	|___|___|___|
j. After Care	|___|___|___|		HIV/AIDS Medical Support	|___|___|___|
k. Recovery Support	|___|___|___|		& Testing
l. Other	|___|___|___|		d. Other
(SPECIFY): ____________________	|___|___|___|		(SPECIFY): _____________	|___|___|___|

SECTION K

SERVICES RECEIVED (CONT.)

THIS SECTION TO BE COMPLETED BY STAFF ONLY

Identify the number of DAYS of services or SESSIONS provided to the client during the client’s course of treatment/recovery. (ENTER ZERO IF NO SERVICES PROVIDED)

4. Case Management Services	Sessions		6. Education Services	Sessions
a. Family Services (Including Marriage			a. Substance Abuse Education	|___|___|___|
Education, Parenting, Child			b. HIV/AIDS Education	|___|___|___|
Development Services)	|___|___|___|		c. Other
b. Child Care	|___|___|___|		(SPECIFY): ___________	|___|___|___|
c. Employment Service
(1) Pre-Employment	|___|___|___|		7. Peer-to-Peer Recovery Support Services
(2) Employment Coaching	|___|___|___|		a. Peer Coaching or Mentoring	|___|___|___|
d. Individual Services Coordination	|___|___|___|		b. Housing Support	|___|___|___|
e. Transportation	|___|___|___|		c. Alcohol- and Drug-Free
f. HIV/AIDS Service	|___|___|___|		Social Activities	|___|___|___|
g. Supportive Transitional Drug-Free			d. Information and Referral	|___|___|___|
Housing Services	|___|___|___|		e. Other
h. Care coordination	|___|___|___|		(SPECIFY): ___________	|___|___|___|
i. Other
(SPECIFY): ___________________	|___|___|___|
5. After Care Services
a. Continuing Care	|___|___|___|
b. Relapse Prevention	|___|___|___|
c. Recovery Coaching	|___|___|___|
d. Self-Help and Support Groups	|___|___|___|
e. Spiritual Support	|___|___|___|
f. Other After Care Services	|___|___|___|
g. Other
(SPECIFY): ___________________	|___|___|___|

END OF INSTRUMENT

End of Section K: Services Received