Form 6-Month Followup 6-Month Followup 6-Month Followup

Attachment 2: SCI 6-Month Follow-up Survey

OMB No. 0930-0320

Expiration Date x/x/x

Substance Abuse and Mental Health Services Administration (SAMHSA)

Evaluation of SAMHSA’S CABHI Program

Client Interview: 6-Month Follow-up

Today’s Date: |___|___| |___|___| |___|___|___|___|
MO DAY YR

CABHI Site Number |___|___|___|___|___| numeric (this will be pre-filled when we print the surveys)

State Subrecipient Number |___|___|___|___|___| numeric (this will be pre-filled when we print the surveys)

SAMHSA CSAT GPRA Client ID |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

numeric and character

Interviewer ID |___|___|___|___| numeric

___________________________________________________

Public Burden Statement: 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 0930-0339.  Public reporting burden for this collection of information is estimated to average 20 minutes per respondent, 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Case ID |___|___|___|___|___|___|___|___|___|___| alpha-numeric; pre-filled when we print the surveys

[QUESTION A1 SHOULD BE COMPLETED BY THE INTERVIEWER]

A1. Interviewer, please select the option that best describes you: (select one)

1. I provide services directly to this client.

2. I provide client services for the CABHI project, but not to this client.

3. I provide administrative or oversight services for the CABHI project; I don’t provide client services.

4. I am an evaluation or research staff member of the CABHI project.

PROGRAM STATUS AND SERVICES

[To be completed by the client with the help of the interviewer.]

S1. Are you currently enrolled in the [CABHI PROJECT]?

1. YES (If YES, skip the next set of questions and go to S5a)

0. NO

-88. DON’T KNOW

-99. REFUSED

S2. How many weeks has it been since your participation in the [CABHI PROJECT] ended?

|___|___| Weeks (if less than 1 week, enter 1)

-99. REFUSED

S3. What is the main reason you are no longer participating in the [CABHI PROJECT] anymore?

Only select one response.

1. Completed the program

2. Left program with program staff approval due to outside circumstances (e.g., time and resource constraints such as client began employment, moved away from treatment, became a caretaker for a family member)

3. Left against advice of program staff

4. Was discharged without completing the program

5. Other, specify: __________

S4a. Do you feel that you still need the types of services that you received in the [CABHI PROJECT]?

1. YES (If YES, answer S4b)

0. NO

-88. DON’T KNOW

-99. REFUSED

S4b. Are you receiving these types of services?

1. YES

0. NO

-88. DON’T KNOW

-99. REFUSED

S5a. As part of your participation in the [CABHI Project], did you receive any treatment specifically for substance abuse?

1. YES

0. NO (If NO, skip the next question and go to S6a)

-88. DON’T KNOW

-99. REFUSED

S5b. During the time you were enrolled in the [CABHI Project], about how often did you typically receive treatment specifically for substance abuse?

1. Daily or almost daily

2. Weekly

3. About every other week

4. Monthly

5. Less than once a month

-88. DON’T KNOW

-99. REFUSED

S5c. We would like to know if the substance abuse treatment you received was provided through an evidence-based practice (EBP). With assistance from the project staff person administering this survey, please select the relevant evidence based practice(s) you received.

[Interviewer, please help the client answer this question if they are not sure.]

1. Motivational Enhancement Therapy

2. Assertive Community Treatment (ACT)

3. Intensive Case Management (ICM)

4. Cognitive Behavioral Therapy (CBT)

5. Matrix Model

6. Screening, Brief Intervention and Referral

7. Adolescent Community Reinforcement Approach

8. Didn’t receive an evidence based practice(s)

-88. DON’T KNOW

-99. REFUSED

S6a. As part of your participation in the [CABHI Project], did you receive any treatment specifically for mental health?

1. YES

0. NO (If NO, skip the next question and go to S7a)

-88. DON’T KNOW

-99. REFUSED

S6b. During the time you were enrolled in the program, about how often did you typically receive treatment specifically for mental health?

1. Daily or almost daily

2. Weekly

3. About every other week

4. Monthly

5. Less than once a month

-88. DON’T KNOW

-99. REFUSED

S6c. We would like to know if the mental health treatment you received was provided through an evidence-based practice (EBP). With assistance from the project staff person administering this survey, please select the relevant evidence based practice(s) you received.

[Interviewer, please help the client answer this question if they are not sure.]

1. Illness Management and Recovery

2. Assertive Community Treatment (ACT)

3. Intensive Case Management (ICM)

4. Cognitive Behavioral Therapy (CBT)

5. Wellness Self-Management

6. Wellness Recovery Action Plan (WRAP)

7. Didn’t receive an evidence based practice(s)

-88. DON’T KNOW

-99. REFUSED

[If the client received both substance abuse and mental health treatment (Question S5a & S6a = YES), please ask S7a]

S7a. Typically, was the substance abuse and mental health treatment you received integrated, meaning that you addressed both issues at the same time with the same person or in the same setting?

1. YES (If YES, answer S7b)

0. NO

-88. DON’T KNOW

-99. REFUSED

S7b. We would like to know if the integrated substance abuse and mental health treatment you received was provided through an evidence-based practice (EBP). With assistance from the project staff person administering this survey, please select the relevant evidence based practice(s) you received.

[Interviewer, please help the client answer this question if they are not sure.]

1. Integrated Dual Disorder Treatment (IDDT)

2. Double Trouble in Recovery

3. Didn’t receive an evidence based practice(s)

-88. DON’T KNOW

-99. REFUSED

S8a. As part of your participation in the [CABHI Project], did you receive any trauma-specific treatment (that is, services to address traumatic experiences)?

1. YES

0. NO (If NO, skip the next question and go to the Homeless and Housing section)

-88. DON’T KNOW

-99. REFUSED

S8b. During the time you were enrolled in the [CABHI Project], about how often did you typically receive trauma-specific treatment (that is, services to address traumatic experiences)?

1. Daily or almost daily

2. Weekly

3. About every other week

4. Monthly

5. Less than once a month

-88. DON’T KNOW

-99. REFUSED

S8c. We would like to know if the trauma-specific treatment you received was provided through an evidence-based practice (EBP). With assistance from the project staff person administering this survey, please select the relevant evidence based practice(s) you received.

[Interviewer, please help the client answer this question if they are not sure.]

1. Seeking Safety

2. Trauma Recovery and Empowerment Model (TREM)

3. Didn’t receive an evidence based practice(s)

-88. DON’T KNOW

-99. REFUSED

HOMELESSNESS AND HOUSING

[INTERVIEWER, please reference the Calendar Showcard with the client for the next set of questions]

H1. Now I want you to think about where you have been living for the past 6 months. We would like to know about all the places you have stayed during the past 6 months, including any shelters or hospitals.

Let’s look at this calendar together. Today is (insert date _____/______/ _ ___). Let’s begin by talking about where you are living now and work backwards to 6 months ago (insert date __ __/ __ __/ __ __).

LIVING SITUATION CODES

01. House, apartment or room rented by the client (or a paid caregiver) 02. House, apartment or room owned by the client (or a paid caregiver) 03. Transitional housing like a halfway house, Oxford House, ¾ housing or safe haven (there is a time limit on how long you can stay, like 3 or 6 months or up to 2 years) 04. A family member’s or friend’s room, apartment, or house 05. Hotel or motel 06. Substance abuse treatment facility or detoxification center 07. Residential treatment (substance abuse or mental health)

08. Psychiatric hospital or other psychiatric facility 09. Long-term care facility or nursing home 10. Hospital or other residential non-psychiatric medical facility 11. Foster care home or foster care group home 12. Jail, prison, or juvenile detention facility 13. Emergency shelter (including a domestic violence shelter) 14. A place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport, or anywhere outside) 15. Another place that hasn’t been mentioned

H1a1. Where are you living right now? [Enter the living situation code in Row 1, Column A]

H1b1. Approximately what date did you begin living in this location? [Enter the response in Row 1, Column B]

[If the client cannot provide a date, ask the client to estimate how long they have been living in the location. Using the calendar, use the length of time to estimate the move-in date.]

[If the move-in date is less than six months from today’s date, go to the next row and ask the client where they were living before.]

H1a2. Where were you living before where you’re living now? [Enter the response in Column A]

H1b2. Approximately what date did you begin living in that location? If you don’t know the date, about how long did you stay there? [Enter the response in Column B]

[Continue to the next row until you have documented ALL of the client’s locations in the past 6 months. This includes moves between the same type of location. For example, if the client moved from one shelter to another shelter, both stays in the shelter should be separately recorded in the table.]

	About the Place			About the Move
Place	A Type of Housing		B Date Moved In	C If they moved INTO: (1) House/apt/room rented by the client (2) House/apt/room owned by the client (3) Transitional housing	D If they moved OUT OF: (1) House/apt/room rented by the client (2) House/apt/room owned by the client (3) Transitional housing
	Write the living situation code that best describes where the client was living	If “other”, specify:	(MM/DD/YY)	Did you receive support to be able to obtain or move into this housing? If so, what type(s) of support? [CHECK ALL THAT APPLY]	What was the main reason or reasons you moved out? [CHECK ALL THAT APPLY]
#1 (current location)	|___|___|		__ __ /__ __/___ __	Support to move into #1 __ Housing application or interview __ Getting higher priority on waiting list __ Working with the landlord or property manager __ Getting the utilities set up __ Moving in or resources (e.g. furniture or household items) __ Paying up-front costs (e.g. deposit) __ Ongoing payment supports (e.g. vouchers) __ Other (specify): __ Did not receive support for this move
#2 (before #1)	|___|___|		__ __ /__ __/___ __	Support(s) to move into #2 __ Housing application or interview __ Getting higher priority on waiting list __ Working with the landlord or property manager __ Getting the utilities set up __ Moving in or resources (e.g. furniture or household items) __ Paying up-front costs (e.g. deposit) __ Ongoing payment supports (e.g. vouchers) __ Other (specify): __ Did not receive support for this move	Reason(s) for moving from #2 __ Found a nicer place or better location __ Could not afford rent or expenses __ Did not meet requirements __ Did not follow rules __ Wanted a place with fewer rules __ Did not like my roommates or neighbors __ Other, specify: _________________
#3 (before #2)	|___|___|		__ __ /__ __/___ __	Support(s) to move into #3 __ Housing application or interview __ Getting higher priority on waiting list __ Working with the landlord or property manager __ Getting the utilities set up __ Moving in or resources (e.g. furniture or household items) __ Paying up-front costs (e.g. deposit) __ Ongoing payment supports (e.g. vouchers) __ Other (specify): __ Did not receive support for this move	Reason(s) for moving from #3 __ Found a nicer place or better location __ Could not afford rent or expenses __ Did not meet requirements __ Did not follow rules __ Wanted a place with fewer rules __ Did not like my roommates or neighbors __ Other, specify: _________________
#4 (before #3)	|___|___|		__ __ /__ __/___ __	Support(s) to move into #4 __ Housing application or interview __ Getting higher priority on waiting list __ Working with the landlord or property manager __ Getting the utilities set up __ Moving in or resources (e.g. furniture or household items) __ Paying up-front costs (e.g. deposit) __ Ongoing payment supports (e.g. vouchers) __ Other (specify): __ Did not receive support for this move	Reason(s) for moving from #4 __ Found a nicer place or better location __ Could not afford rent or expenses __ Did not meet requirements __ Did not follow rules __ Wanted a place with fewer rules __ Did not like my roommates or neighbors __ Other, specify: _________________

INTERVIEWER, please ask questions H2a-H2f only if the client is currently living in 01- House, apartment or room rented by the client, 02 - House, apartment or room owned by the client, or 03-A transitional housing program.

If you live in your own apartment/house/room, a permanent housing program, or a transitional housing program:

H2a. Do you either own your apartment/house/room or do you have a lease in your name?

1. YES, I own.

2. YES, I have a lease in my name. (If YES, answer H2B)

0. NO

-77. DON’T KNOW

-99. REFUSED

H2b. If you have a lease, how long does it last?

1. Less than 6 months

2. 6 months to less than 1 year

3. 1 year to less than 2 years

4. 2 years or more

-77. DON’T KNOW

-99. REFUSED

H2c. Do you receive services to help you keep your housing? For example, help dealing with your landlord.

1. YES, at the place where I am living or staying.

2. YES, somewhere other than the place where I am living or staying.

3. YES, both where I am living/staying and in other places.

0. NO

-77. DON’T KNOW

-99. REFUSED

H2d. Do you receive money or subsidies to help you pay for your housing?

1. YES

0. NO (If NO, skip to H2f)

-77. DON’T KNOW

-99. REFUSED

H2e. Is a voucher one way in which you receive help to pay for your housing?

1. YES

0. NO

-77. DON’T KNOW

-99. REFUSED

H2f. What portion of the rent do you pay yourself?

1. 0% (I don’t pay for any of the rent myself)

2. 1-25%

3. 26-50%

4. 51-75%

5. 76-100%

-77. DON’T KNOW

-99. REFUSED

INTERVIEWER, please ask questions H3A-H3D only if the client is currently living in 01- House, apartment or room rented by the client, 02 - House, apartment or room owned by the client, or 03-A transitional housing program.

H3. The next questions refer to where you live now, your current housing situation. The following statements are about the requirements that may be a part of your housing. Please indicate how much you ‘agree’ or ‘disagree’ with each statement. You may use this card (HAND RESPONDENT SHOW CARD #1) to indicate your responses.

Statement	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree	Don’t know	Not applicable	Refused
H3a. You must stay in mental health treatment to continue living in your current housing.	1	2	3	4	5	-77	-88	-99
H3b. You must stay in drug or alcohol treatment to continue living in your current housing.	1	2	3	4	5	-77	-88	-99
H3c. You would be allowed to stay in the place where you currently live if you discontinued mental health services.	1	2	3	4	5	-77	-88	-99
H3d. You would be allowed to stay in the place where you currently live if you broke program rules about alcohol or drug use.	1	2	3	4	5	-77	-88	-99

H4. Did you have any problems finding a place to live during the past 6 months? 1. _____YES 0. _____NO (If NO, skip to next question, H10) -99. REFUSED

H5. If yes, what types of problems did you have finding a place to live in the past 6 months? [READ THE TYPES OF PROBLEMS BELOWAND MARK “YES” OR “NO” FOR EACH ITEM.]

		Yes	No	Refused
H5a.	Finding a place I could afford	1	0	-99
H5b.	Finding a place in a safe neighborhood	1	0	-99
H5c.	Having the rent deposit together	1	0	-99
H5d.	My credit wasn’t good	1	0	-99
H5e.	Problems because of a criminal record	1	0	-99
H5f.	Trouble finding a place big enough for my family	1	0	-99
H5g.	Finding a place where my partner and I are allowed to live together	1	0	-99
H5h.	Finding a place where my children and I are allowed to live together	1	0	-99
H5i.	Finding a place near transportation	1	0	-99
H5j.	Need to complete treatment before I can get housing.	1	0	-99
H5k.	Need to be clean and sober before I can get housing.	1	0	-99
H5l.	Discrimination, specify:	1	0	-99
H5m.	Other problem, specify:	1	0	-99

H6. Now, I will ask you about how you feel about where you live now. After I read each item, please let me know how satisfied you are with your housing. You may use this card (HAND RESPONDENT SHOW CARD #2) to indicate your responses.

Statement	Very Dissatisfied	Dissatisfied	Neither Satisfied Nor Dissatisfied	Satisfied	Very Satisfied	Don’t know	Not Applicable	Refused
H6a. The amount of choice you have over where you live	1	2	3	4	5	-77	-88	-99
H6b. The safety of your neighborhood	1	2	3	4	5	-77	-88	-99
H6c. The amount of privacy you have	1	2	3	4	5	-77	-88	-99
H6d. How affordable your place is	1	2	3	4	5	-77	-88	-99
H6e. The condition or state of repair of your place	1	2	3	4	5	-77	-88	-99
H6f. The safety and security of where you live	1	2	3	4	5	-77	-88	-99
H6g. The opportunities you have to socialize in the place where you live	1	2	3	4	5	-77	-88	-99
H6h. Overall, how satisfied do you feel about living here?	1	2	3	4	5	-77	-88	-99

criminal justice

Have you ever been arrested, booked, or taken into custody (including through remand) in the past?	1. YES 0. NO (If NO, skip to next section, K1) -77. DON’T KNOW -99. REFUSED
Have you been arrested, booked, or taken into custody (including through remand) in the past 6 months that is since / / ?	1. YES 0. NO (If NO, skip to next section, K1) -77. DON’T KNOW -88. N/A -99. REFUSED
/ / How many times have you been arrested, booked, or taken into custody (including through remand) in the past 6 months that is since ?	|___|___| # TIMES numeric (0-99) -77. DON’T KNOW -88. N/A -99. REFUSED

TREATMENT HISTORY, Needs and Services

K. The following questions ask about how you have been feeling during the past 30 days. For each question, please indicate how often you had this feeling. You may use this card (HAND RESPONDENT SHOW CARD #4) to indicate your responses.

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	Don’t know	Not applicable	Refused
K1. nervous?	1	2	3	4	5	-77	-88	-99
K2. hopeless?	1	2	3	4	5	-77	-88	-99
K3. restless or fidgety?	1	2	3	4	5	-77	-88	-99
K4. so depressed that nothing could cheer you up?	1	2	3	4	5	-77	-88	-99
K5. that everything was an effort?	1	2	3	4	5	-77	-88	-99
K6. worthwhile?	1	2	3	4	5	-77	-88	-99

PCL1. Now, I’m going to read a list of problems and complaints people sometimes have in response to stressful life experiences. For each item, please tell me how much you’ve been bothered by that problem in the past 30 days (e.g., the past month). You may use this card (HAND RESPONDENT SHOW CARD #5) to indicate your responses.

In the past month how much have you been bothered by…	Not at all	Somewhat	Moderately	Considerably	Extremely	DK	NA	RF
PCL1a. Repeated disturbing memories, thoughts, or images of a stressful experience from the past?	1	2	3	4	5	-77	-88	-99
PCL1b. Feeling very upset when something reminded you of a stressful experience from the past?	1	2	3	4	5	-77	-88	-99
PCL1c. Avoiding activities or situations because they reminded you of a stressful experience from the past?	1	2	3	4	5	-77	-88	-99
PCL1d. Feeling distant or cut off from other people?	1	2	3	4	5	-77	-88	-99
PCL1e. Feeling irritable or having angry outbursts?	1	2	3	4	5	-77	-88	-99
PCL1f. Having difficulty concentrating?	1	2	3	4	5	-77	-88	-99

SV. Now I am going to ask you about services you may have needed and/or received in the last 6 months, that is, since . Please indicate with a ‘yes’ or ‘no’ if you have needed any of the following

s

/ /

ervices and then if you have received the following services.

	YES	NO	DK	NA	RF
a. Did you need any substance abuse treatment services, such as substance abuse education, individual or group counseling, residential treatment, etc. (do not include case management services)?	1	0	-77	-88	-99
b. Did you receive any of these substance abuse treatment services? <If no, skip to SV2>	1	0	-77	-88	-99
a. Did you need any mental health treatment, such as individual, family, or group therapy, day treatment, or inpatient treatment? (do not include case management services)	1	0	-77	-88	-99
b. Did you receive any mental health treatment, such as individual, family, or group therapy, day treatment, or inpatient treatment? (do not include case management services) <If no, skip to SV3>	1	0	-77	-88	-99
a. Did you need any trauma-specific treatment; that is, groups or services to address traumatic experiences?	YES	NO	DK	NA	RF
	1	0	-77	-88	-99
b. Did you receive any trauma-specific treatment or services (e.g., TREM (Trauma Recovery Empowerment Motivation), Seeking Safety, etc.)?	1	0	-77	-88	-99
a. Did you need psychiatric medication or to see a doctor or nurse about psychiatric medication that you are already taking?	1	0	-77	-88	-99
b. Did you receive psychiatric medication(s)? <If no, skip to SV5>	1	0	-77	-88	-99
c. Did you see a doctor or nurse to help you manage your psychiatric medication(s)?	1	0	-77	-88	-99
a. Did you need help accessing or participating in treatment or other services; for example, by a case manager?	YES	NO	DK	NA	RF
	1	0	-77	-88	-99
b. Did you receive help accessing or participating in treatment or other services?	1	0	-77	-88	-99
a. Did you need any medical/health care services (including eye and dental care)?	1	0	-77	-88	-99
b. Did you receive any medical/health care services (including eye and dental care)?	1	0	-77	-88	-99
a. Did you need any services related to employment or education?	1	0	-77	-88	-99
Did you receive any services related to employment or education?	1	0	-77	-88	-99
a. Did you need any help with housing services; for example, help finding shelter or housing, dealing with a landlord or eviction, help getting a housing subsidy?	1	0	-77	-88	-99
b. Did you receive any help with housing services?	1	0	-77	-88	-99
a. Did you need any help addressing basic needs, such as food, clothing, or hygiene products?	1	0	-77	-88	-99
b. Did you receive any help addressing these basic needs?	1	0	-77	-88	-99
a. Did you need any help applying for income supports, such as SSI, SSDI, TANF or SNAP?	1	0	-77	-88	-99
b. Did you receive any help applying for any of these income supports?	1	0	-77	-88	-99
a. Did you need any help applying for healthcare benefits, such as Medicaid, Medicare, or some other type of healthcare plan?	1	0	-77	-88	-99
b. Did you receive any help applying for healthcare benefits?	1	0	-77	-88	-99
a. Did you need any help with transportation to meet basic needs; for example, help getting to work or appointments?	1	0	-77	-88	-99
b. Did you receive any help with transportation?	1	0	-77	-88	-99
a. Did you need/want to participate in any self-help or peer support services? Self-help and peer support refers to activities led by people with substance abuse or mental health/psychiatric problems to share their strengths and help each other cope and grow. It does not include support groups led by service providers who are not peers.	1	0	-77	-88	-99
b. Did you participate in any self-help or peer support services?	1	0	-77	-88	-99
a. Did you need any childcare services; that is, help finding childcare or obtaining a subsidy or other financial support for childcare?	1	0	-77	-88	-99
b. Did you receive any childcare services?	1	0	-77	-88	-99
a. Did you need any legal assistance services?	1	0	-77	-88	-99
c. Did you receive any legal assistance services?	1	0	-77	-88	-99

Have you experienced any of the following problems participating in the [CABHI Project] services or have any of these problems prevented you from participating in treatment services? [READ RESPONSES AND MARK “YES” OR “NO” FOR ALL THAT APPLY.]
		Yes	No	DK	NA	RF
CTB1a.	Problems fitting treatment services into schedule.	1	0	-77	-88	-99
CTB1b.	Problems finding childcare to attend services.	1	0	-77	-88	-99
CTB1c.	Problems paying for childcare to attend services.	1	0	-77	-88	-99
CTB1d.	Problems paying for fees or copayments for services.	1	0	-77	-88	-99
CTB1e.	Problems getting transportation to and from the program.	1	0	-77	-88	-99
CTB1f.	Too many steps to participate in the program.	1	0	-77	-88	-99
CTB1g.	Program services do not fit with work or school schedule.	1	0	-77	-88	-99
CTB1h.	Program doesn’t have staff that speaks your language.	1	0	-77	-88	-99
CTB1i.	Did not have any problems.	1	0	-77	-88	-99

Please tell us about how much it cost you in time and money in a typical month to attend services. (If client needs assistance, please review with the client the services they self-reported as received in the previous section, SV1 – SV15)
CTB2. Costs in Terms of Time
CTB2.	Approximate time spent getting to and from and participating in services.	_______ hours per month -88. N/A -99. REFUSED

CTB3. Costs in Terms of Money
CTB3a.	If you worked since the last interview, what was the hourly wage at your most recent or current job?	$ _________ -88. N/A -99. REFUSED
CTB3b.	Did you lose pay from work because of receiving services?	1. YES 0. NO -88. N/A -99. REFUSED
CTB3c.	Approximate monthly costs of getting to and from the services.	$ _________ -88. N/A -99. REFUSED
CTB3d.	Approximate monthly cost of fees and copayments for services.	$ _________ -88. N/A -99. REFUSED
CTB3e.	Approximate monthly costs of additional childcare needed to travel to and receive services.	$ _________ -88. N/A -99. REFUSED
CTB3f.	Other Costs, specify:________________________________	$ _________ -88. N/A -99. REFUSED
CTB3g.	Did not have any costs.	1. YES 0. NO -77. DON’T KNOW -99. REFUSED

BENEFITS assistance and insurance

a. Do you currently receive SSI (Supplemental Security Income) or SSDI (Social Security Disability Insurance) benefits? <If yes, skip to BA2>	1. YES 0. NO -77. DON’T KNOW -99. REFUSED
b. Have you applied for SSI or SSDI? <If yes, skip to BA2>	1. YES 0. NO -77. DON’T KNOW -99. REFUSED
c. Are you planning to apply for SSI or SSDI?	1. YES 0. NO -77. DON’T KNOW -99. REFUSED
a. Are you currently enrolled in Medicaid? <If yes, skip to BA3>	1. YES 0. NO -77. DON’T KNOW -99. REFUSED
b. Are you covered by any other type of insurance; for example, Tricare, Medicare, private?	1. YES 0. NO -77. DON’T KNOW -99. REFUSED
a. Do you currently receive TANF (Temporary Assistance for Needy Families) or SNAP (Supplemental Nutrition Assistance Program) benefits? <If yes, this section is complete; begin Part II>	1. YES 0. NO -77. DON’T KNOW -99. REFUSED
b. Have you applied for TANF or SNAP? <If yes, this section is complete; begin Part II>	1. YES 0. NO -77. DON’T KNOW -99. REFUSED
c. Are you planning to apply for TANF or SNAP?	1. YES 0. NO -77. DON’T KNOW -99. REFUSED

CH1. How many children under the age of 18 are currently living with you? |___|___|

EVALUATION OF SAMHSA’S CABHI PROGRAM

Client Interview Part II for Self-Completion — 6-Month Follow-up:

Perception of Care

[Interviewers please note: Two sheets with 21 questions are separately provided to the participant by the GPRA interviewer. Please have clients complete these questions on their own and put them into the provided envelope and seal them and return to the interviewer—see Client Informed Consent Script]

Today’s Date: |___|___| |___|___| |___|___|___|___| numeric
MO DAY YR

CABHI Site Number |___|___|___|___|___| numeric

State Subrecipient Number |___|___|___|___|___| numeric (this will be pre-filled when we print the surveys)

SAMHSA CSAT GPRA Client ID |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

numeric and character

Case ID |___|___|___|___|___|___|___|___|___| numeric; pre-filled when we print the surveys

Thank you for taking the time to complete these questions.

Please complete the following 21 questions and when you are done, please put them in the envelope you were given, seal it and give it to the GPRA interviewer.

PC. In order to provide the best possible services, we need to know what you think about the services you received in the past, before this program, the people who provided it, and the results. Please indicate your disagreement/agreement with each of the following statements.

Statement	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
PC1. Staff believed that I could grow, change, and recover.	1	2	3	4	5
PC2. I felt free to complain.	1	2	3	4	5
PC3. I was given information about my rights.	1	2	3	4	5
PC4. Staff encouraged me to take responsibility for how I live my life.	1	2	3	4	5
PC5. Staff told me what side effects to watch out for.	1	2	3	4	5
PC6. Staff respected my wishes about who is and who is not to be given information about my treatment.	1	2	3	4	5
PC7. Staff were sensitive to my cultural background (race, religion, language, etc.).	1	2	3	4	5
PC8. Staff helped me obtain the information I needed so that I could take charge of my illness.	1	2	3	4	5
PC9. I was encouraged to use consumer run programs (support groups, drop-in centers, crisis phone line, etc.).	1	2	3	4	5
PC10. I felt comfortable asking questions about my treatment and medication.	1	2	3	4	5
PC11. I, not staff, decided my treatment goals.	1	2	3	4	5
PC12. I liked the services I received.	1	2	3	4	5

TCC. The following questions are about what you may have been told about participating in services provided by the CABHI program. Please indicate with a ‘Yes’ or ‘No’ if you were told the following about participating in the CABHI program.

Were you told that if you do not participate in your program you would lose your income benefits? Benefits like TANF/DSS, Medicaid, Social Security Insurance (SSI), Social Security Disability Insurance (SSDI), or any other benefits for which you receive money.	1. YES 0. NO 3. Do not have benefits
Were you told that if you do not participate in your program you would lose your housing benefits? Housing benefits like Section 8, a housing subsidy, or any other type of housing voucher.	1. YES 0. NO 3. Do not have housing benefits
Were you told if you do not participate in your program you would lose custody of your children?	1. YES 0. NO 3. Do not have children
Are you court-ordered to participate in your program?	1. YES 0. NO
If you are taking any medications for mental health problems, were you told that you would have to stop taking these medications to get substance abuse treatment?	1. YES 0. NO 3. Not taking medications
If you are currently in substance abuse treatment, were you told that you needed to be “clean and sober” to get mental health treatment?	1. YES 0. NO 3. Not in substance abuse treatment
If you are currently in substance abuse treatment, were you told that you needed to be “clean and sober” to get substance abuse treatment?	1. YES 0. NO 3. Not in substance abuse treatment
Were you told you had to stay in substance abuse or mental health treatment to get housing or stay in housing?	1. YES 0. NO 3. Not in treatment
If you wanted to, could you switch to another program that provides the same types of services you receive from here?	1. YES 0. NO

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