CMHS NOMS Data Col CMHS NOMS Data Collection Tool

ATTACHMENT A

Form Approved

OMB No. 0930-0285

Expiration Date 02/28/2022

Substance Abuse and Mental Health Services Administration (SAMHSA)

Center for Mental Health Services (CMHS)

National Outcome Measures (NOMs) Client-Level Measures for Discretionary Programs Providing Direct Services

SERVICES TOOL

SAMHSA’s Performance Accountability and Reporting System (SPARS)

May 2021

Public reporting burden for this collection of information is estimated to average 40 minutes per response if all items are asked of a consumer/participant; to the extent that providers already obtain much of this information as part of their ongoing consumer/participant intake or follow-up, less time will be required. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The control number for this project is 0930-0285.

Table of Contents

RECORDS MANAGEMENT 1

DEMOGRAPHIC DATA 2

BEHAVIORAL HEALTH DIAGNOSES – This section should be completed by a licensed clinician 4

B. STABILITY IN HOUSING 11

C. EDUCATION AND EMPLOYMENT 12

D. CRIME AND CRIMINAL JUSTICE STATUS 13

E. PERCEPTION OF CARE 14

F. SOCIAL CONNECTEDNESS 16

G. PROGRAM-SPECIFIC QUESTIONS 17

G1. PROGRAM-SPECIFIC QUESTIONS: ASSISTED OUTPATIENT TREATMENT 18

G2. PROGRAM-SPECIFIC QUESTIONS: LAW ENFORCEMENT AND BEHAVIORAL HEALTH PARNTERSHIPS FOR EARLY DIVERSION 19

G3. PROGRAM-SPECIFIC QUESTIONS: PROMOTING THE INTEGRATION OF PRIMARY AND BEHAVIORAL HEALTH CARE 20

G4. PROGRAM-SPECIFIC QUESTIONS: MINORITY AIDS – SERVICE INTEGRATION 21

G5. PROGRAM-SPECIFIC QUESTIONS: HEALTHY TRANSITIONS 23

G6. PROGRAM-SPECIFIC QUESTIONS: ASSERTIVE COMMUNITY TREATMENT 24

G7. PROGRAM-SPECIFIC QUESTIONS: CLINICAL HIGH RISK FOR PSYCHOSIS 25

G8 PROGRAM-SPECIFIC QUESTIONS: CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS 26

G9 PROGRAM-SPECIFIC QUESTIONS: NATIONAL CHILD TRAUMATIC STRESS INITIATIVE – CATEGORY 3 27

H. SERVICES RECEIVED AND CLINICAL DISCHARGE STATUS 28

[This page intentionally left blank]

RECORDS MANAGEMENT

Records Management information is collected by Grantee Staff at BASELINE, REASSESSMENT, and DISCHARGE, even when an assessment interview is not conducted.

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

Grant ID |____|____|____|____|____|____|____|____|____|____|____|

Site ID |____|____|____|____|____|____|____|____|____|____|

1. Indicate Assessment Type:

    Baseline Assessment	 Reassessment (3-month or 6-month)	 Clinical Discharge Assessment
   Enter the MONTH and YEAR when the consumer first received services under this grant for this episode of care.
   |____|____| / |____|____|____|____| MONTH YEAR

2. Was the assessment interview conducted?

 Yes	 No
When? |____|____| / |____|____| / |____|____|____|____| MONTH DAY YEAR	Why not? Choose only one.  Not able to obtain consent from proxy  Client/consumer was impaired or unable to provide consent  Client/consumer refused this interview  Client/consumer was not reached for interview  Client/consumer refused all interviews

3. For children, was the respondent the child or the caregiver?

Child

Caregiver

DEMOGRAPHIC DATA

1. What do you consider yourself to be? [Read choices.]

Male

Female

Transgender (Male to Female)

Transgender (Female to Male)

Gender non-conforming

Other (Specify)______________________________

Refused

2. Do you think of yourself as…

Straight Or Heterosexual

Homosexual (Gay Or Lesbian)

Bisexual

Queer

Pansexual

Questioning

Asexual

Something Else? Please Specify ___________________________________

Refused

3. Are you Hispanic, Latino/a, or Spanish origin?

 Yes

 No [GO TO 4.]

 Refused [GO TO 4.]

[IF YES] What ethnic group do you consider yourself? You may indicate more than one.

Central American

Cuban

Dominican

Mexican

Puerto Rican

South American

Other (Specify)_____________

Refused

4. What is your race? You may indicate more than one.

   Race
   Black or African American White
   American Indian
   Alaska Native
   South Asian
   Chinese
   Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Other (Specify)___________________

5. Do you speak a language other than English at home? (5 years old or older)

• Yes

• No

IF YES, what is this language? (5 years old or older)

• Spanish

• Other ___________

6. What is your month and year of birth?

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

Month Year

7. [ADULT ONLY] Have you ever served in the Armed Forces, the Reserves, or the National Guard?

• Yes

• No

• Don’t know

• Not applicable

8. [ADULT ONLY] Are you currently serving on active duty in the Armed Forces, the Reserves, or the National Guard?

• Yes

• No

• Refused

• Don’t Know

Stop here if a BASELINE ASSESSMENT interview was not conducted.

BEHAVIORAL HEALTH DIAGNOSES – This section should be completed by a licensed clinician

1. Was the client/consumer screened or assessed by your program for trauma-related experiences:

• Yes

• No

• Don’t know

If “no”, please select why:

• No time during interview

• No training around trauma screening/disclosure

• No institutional/organizational policy around screening

• No referral network and/or infrastructure for trauma services currently available

• Other

If screened/assessed, was the screen positive?

• Yes

• No

• Don’t know

2. Did the client/consumer have a positive suicidal screen?

• Yes

• No

• Don’t know

If Yes, was a suicidal safety plan developed?

• Yes

• No

• Don’t know

If Yes, was access to lethal means assessed?

• Yes

• No

• Don’t know

3. Behavioral Health Diagnoses [This data is reported by Grantee Program Staff]

Please indicate the client/consumer’s current behavioral health diagnoses using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes listed below. Please note that some substance use disorder ICD-10-CM codes have been crosswalked to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) descriptors. Select up to three mental health diagnoses. If there are any co-occurring disorders, you may select up to three substance use disorders.

If no mental health diagnosis, select reason:

• No clinician assessment

• High risk factors requiring intervention and not yet meeting criteria for a DSM/ICD diagnosis

• Only met criteria for a “Z “code

 Other (please specify_______________________________________)

MENTAL HEALTH DIAGNOSES	Diagnosed?
Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders
F20 – Schizophrenia	
F21 – Schizotypal disorder	
F22 – Delusional disorder	
F23 – Brief psychotic disorder	
F24 – Shared psychotic disorder	
F25 – Schizoaffective disorders	
F28 – Other psychotic disorder not due to a substance or known physiological condition	
F29 – Unspecified psychosis not due to a substance or known physiological condition	
Mood [affective] disorders]
F30 – Manic episode	
F31 – Bipolar disorder	
F32 – Major depressive disorder, single episode	
F33 – Major depressive disorder, recurrent	
F34 – Persistent mood [affective] disorders	
F39 – Unspecified mood [affective] disorder	
Phobic Anxiety and Other Anxiety Disorders
F40 – Phobic anxiety disorders	
F40.00 – Agoraphobia, unspecified	
F40.01 – Agoraphobia with panic disorder	
F40.02 – Agoraphobia without panic disorder	
F40.1 – Social phobias (Social anxiety disorder)	
F40.10 – Social phobia, unspecified	
F40.11 – Social phobia, generalized	
F40.2 – Specific (isolated) phobias	
F41 – Other anxiety disorders	
F41.0 – Panic disorder	
F41.1 – Generalized anxiety disorder	
Obsessive-compulsive disorders
F42 – Obsessive-compulsive disorder	
F42.2 – Obsessive-compulsive disorder with mixed obsessional thoughts and acts	
F42.3 – Hoarding disorder	
F42.4 – Excoriation (skin-picking) disorder	
F42.8 – Other obsessive-compulsive disorder	
F42.9 – Obsessive-compulsive disorder, unspecified	
Reaction to severe stress and adjustment disorders
F43 – Acute stress disorder; reaction to severe stress, and adjustment disorders	
F43.10 – Post traumatic stress disorder, unspecified	
F43.2 – Adjustment disorders	
F44 – Dissociative and conversion disorders	
F44.81 – Dissociative identity disorder	
F45 – Somatoform disorders	
F45.22 – Body dysmorphic disorder	
F48 – Other non-psychotic mental disorders	
Behavioral syndromes associated with physiological disturbances and physical factors
F50 – Eating disorders	
F51 – Sleep disorders not due to a substance or known physiological condition	
Disorders of adult personality and behavior
F60.0 – Paranoid personality disorder	
F60.1 – Schizoid personality disorder	
F60.2 – Antisocial personality disorder	
F60.3 – Borderline personality disorder	
F60.4 – Histrionic personality disorder	
F60.5 – Obsessive-compulsive personality disorder	
F60.6 – Avoidant personality disorder	
F60.7 – Dependent personality disorder	
F60.8 – Other specific personality disorders	
F60.9 – Personality disorder, unspecified	
F63.3 – Trichotillomania	
F70–F79 – Intellectual disabilities	
F80–F89 – Pervasive and specific developmental disorders	
Behavioral and emotional disorders with onset usually occurring in childhood and adolescence
F90 – Attention-deficit hyperactivity disorders	
F91 – Conduct disorders	
F93 – Emotional disorders with onset specific to childhood	
F93.0 – Separation anxiety disorder of childhood	
F94 – Disorders of social functioning with onset specific to childhood or adolescence	
F94.0 – Selective mutism	
F94.1 – Reactive attachment disorder of childhood	
F94.2 – Disinhibited attachment disorder of childhood	
F95 – Tic disorder	
F98 – Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence	
F99 – Unspecified mental disorder	
Z codes – Persons with potential health hazards related to socioeconomic and psychosocial circumstances
Z55 – Problems related to education and literacy	
Z56 – Problems related to employment and unemployed	
Z57 – Occupational exposure to risk factors	
Z59 – Problems related to housing and economic circumstances	
Z60 – Problems related to social environment	
Z62 – Problems related to upbringing	
Z63 – Other problems related to primary support group, including family circumstances	
Z64 – Problems related to certain psychological circumstances	
Z65 – Problems related to other psychosocial circumstances	

SUBSTANCE USE DIAGNOSES	Diagnosed?
Alcohol related disorders
F10.10 – Alcohol abuse, uncomplicated	
F10.11 – Alcohol abuse, in remission	
F10.20 – Alcohol dependence, uncomplicated	
F10.21 – Alcohol dependence, in remission	
F10.9 – Alcohol use, unspecified	
Opioid related disorders
F11.10 – Opioid abuse, uncomplicated,	
F11.11 – Opioid abuse, in remission	
F11.20 – Opioid dependence, uncomplicated	
F11.21 – Opioid dependence, in remission	
F11.9 – Opioid use, unspecified	
Cannabis related disorders
F12.10 – Cannabis abuse, uncomplicated	
F12.11 – Cannabis abuse, in remission	
F12.20 – Cannabis dependence, uncomplicated	
F12.21 – Cannabis dependence, in remission	
F12.9 – Cannabis use, unspecified	
Sedative, hypnotic, or anxiolytic related disorders
F13.10 – Sedative, hypnotic, or anxiolytic abuse, uncomplicated	
F13.11 – Sedative, hypnotic, or anxiolytic abuse, in remission	
F13.20 – Sedative, hypnotic, or anxiolytic dependence, uncomplicated	
F13.21 – Sedative, hypnotic, or anxiolytic dependence, in remission	
F13.9 – Sedative, hypnotic, or anxiolytic-related use, unspecified	
Cocaine related disorders
F14.10 – Cocaine abuse, uncomplicated	
F14.11 – Cocaine abuse, in remission	
F14.20 – Cocaine dependence, uncomplicated	
F14.21 – Cocaine dependence, in remission	
F14.9 – Cocaine use, unspecified	
Other stimulant related disorders
F15.10 – Other stimulant abuse, uncomplicated	
F15.11 – Other stimulant abuse, in remission	
F15.20 – Other stimulant dependence, uncomplicated	
F15.21 – Other stimulant dependence, in remission	
F15.9 – Other stimulant use, unspecified	
Hallucinogen related disorders
F16.10 – Hallucinogen abuse, uncomplicated	
F16.11 – Hallucinogen abuse, in remission	
F16.20 – Hallucinogen dependence, uncomplicated	
F16.21 – Hallucinogen dependence, in remission	
F16.9 – Hallucinogen use, unspecified	
Inhalant related disorders
F18.10 – Inhalant abuse, uncomplicated	
F18.11 – Inhalant abuse, in remission	
F18.20 – Inhalant dependence, uncomplicated	
F18.21 – Inhalant dependence, in remission	
F18.9 – Inhalant use, unspecified	
Other psychoactive substance related disorders
F19.10 – Other psychoactive substance abuse, uncomplicated	
F19.11 – Other psychoactive substance abuse, in remission	
F19.20 – Other psychoactive substance dependence, uncomplicated	
F19.21 – Other psychoactive substance dependence, in remission	
F19.9 – Other psychoactive substance use, unspecified	
Nicotine dependence
F17.20 – Nicotine dependence, unspecified	
F17.21 – Nicotine dependence, cigarettes	

For BASELINE and REASSESSMENT:

• If an interview WAS conducted, go to Section A.

• If an interview WAS NOT conducted go to Section H.

For a CLINICAL DISCHARGE:

• If an interview WAS conducted, go to Section A.

• If an interview WAS NOT conducted, go to Section H.

A. FUNCTIONING

1. How would you rate your [your child’s] overall mental health right now?

 Excellent

 Very Good

 Good

 Fair

 Poor

 No response/refused

2. To provide the best mental health and related services, we need to know how well you [your child] were able to deal with everyday life during the past thirty days. Please indicate your [your child’s] response to each of the following statements:

   During the past 30 days ….	Yes	No	No Response/Refused
   2.a. I am [my child is] handling daily life.			
   2.b. I am [my child is] able to deal with unexpected events in my life.			
   2.c. I [my child does] get along with friends and other people.			
   2.d. I [my child does] get along with family members.			
   2.e. I [my child does] do well in social situations.			
   2.f. I [my child does] do well in school and/or work.			
   2.g. I do [my child does] have had a safe place to live.			

3. The following questions ask about how you [your child] has been feeling during the past 30 days. Please indicate your response to each question:

During the past 30 days, did you [your child] feel …	Yes	No	No Response /Refused
3.a. Nervous?			
3.b. Hopeless?			
3.c. Restless or fidgety?			
			
3.d. So depressed that nothing could cheer you [your child] up?			
3.e. That everything was an effort?			
3.f. Worthless?			
3.g. Bothered by psychological or emotional problems?			

B. STABILITY IN HOUSING

1. In the past 30 days, have you [your child] …	Yes	No	No Response/Refused
Been homeless			
Spent time in a hospital for mental health care			
Spent time in a facility for detox/inpatient treatment for a substance abuse disorder			
Spent time in a correctional facility (e.g., jail, prison, juvenile facility)			
Gone to an emergency room for a mental health or emotional problem.			
Been satisfied with the conditions of your living space.			

2. In the past 30 days, where have you been living most of the time?

[Do not read response options to the client. Select only one.]

• Private residence

• Foster home

• Residential care

• Crisis residence

• Residential treatment center

• Institutional setting

• Jail/correctional facility

• Homeless/shelter

• Other (SPECIFY)

• Don’t know

C. EDUCATION AND EMPLOYMENT

1. Are you [your child] currently enrolled in school or a job training program?

   • Yes

   • No

   • No response/refused

2. [ADULT ONLY] - What is the highest level of education you have finished, whether or not you received a degree?

   • LESS THAN 12TH GRADE

   • 12TH GRADE/HIGH SCHOOL DIPLOMA/EQUIVALENT (GED)

   • VOCATIONAL/TECHNICAL (VOC/TECH) DIPLOMA

   • SOME COLLEGE OR UNIVERSITY

   • BACHELOR’S DEGREE (BA, BS)

   • GRADUATE WORK/GRADUATE DEGREE

   • REFUSED

   • DON’T KNOW

3. [ADULT ONLY) - Are you currently employed?

   • Employed full-time (35+ HOURS per week)

   • Employed, part-time

   • Unemployed –but looking for work

   • Not Employed, NOT looking for work

   • Not working due to a disability

   • Retired, not working

   • Other (SPECIFY)

   • Refused

   • Don’t know

4. In the past 30 days , did you …

Statement	Yes	No	No response or Refused
4.a. Have you enough money to meet your [your child’s] needs?			

^{___________________________
1} For information on federal minimum wage, go to https://www.dol.gov/general/topic/wages

D. CRIME AND CRIMINAL JUSTICE STATUS

1. [ADULT ONLY] In the past 30 days, have you …

Statement	Yes	No	No response/refused
D.1.a. Been arrested?			
D.1.b Spent time in jail or a correctional facility or on probation?			

2. [CHILD ONLY] In the past 30 days, have you

Statement	Yes	No	No response/refused
D.2.a. Been arrested?			
D.2.b Spent time in jail or been on juvenile probation?			

If this is a BASELINE assessment, go to Section F.

If this is a REASSESSMENT or a CLINICAL DISCHARGE assessment, go to Section E.

E. PERCEPTION OF CARE

Go to Section F if this is a BASELINE assessment

Section E data is collected only for the REASSESSMENT interview and the CLINICAL DISCHARGE assessment.

1. In order to provide the best possible mental health and related services, we need to know what you [your child] thinks about the services you received during the past 30 days, the people who provided it, and the results. Please indicate your disagreement/agreement with each of the following statements.

[Read each statement to the client/consumer, followed by the response options]

Statement
	yes	No	No response / Refused
Staff here believe that I [my child] can grow, change, and recover.			
I [my child] felt free to complain.			
I [my child] was given information about my rights.			
Staff encouraged me [my child] to take responsibility for how I live my life.			
Staff told me [my child] what side effects to watch out for.			
Staff respected my [my child’s] wishes about who is and who is not to be given information about my treatment.			
Staff were sensitive to my [my child’s] cultural background (e.g., race, religion, language).			
Staff helped me [my child] obtain the information I [my child] needed so that I [my child] could take charge of managing my [his/her] illness.			
I [my child] was encouraged to use consumer-run programs (support groups, drop-in centers, crisis phone line, etc.).			
I [my child] felt comfortable asking questions about my treatment and medication.			
I, not staff, decided my treatment goals.			
I [my child] like[s] the services received here.			
I [my child] would still get services from this agency if there were other choices.			
I would recommend this agency to a friend or family member.			

Indicate who administered Section F to the client/consumer for this interview:

 Administrative staff

• Care coordinator

• Case manager

• Clinician providing direct services

• Clinician not providing direct services

• Consumer/peer

• Data collector/evaluator

• Family advocate

• Other (SPECIFY)

F. SOCIAL CONNECTEDNESS

1. Please indicate YES or NO for each of the following statements. Please answer for relationships with persons other than your mental health provider(s) over the past 30 days.

[Read each statement to the client/consumer, followed by the response options]

STATEMENT
	Yes	No	No response / Refused
I [my child is] am happy with my [their] friendships.			
b. I have [my child has] people with whom I [they] can do enjoyable things.			
c. I feel [my child feels] that I [they] belong in the community.			
d. In a crisis, I [my child] would have the support needed from family or friends.			
e. I have [my child has] family or friends that are supportive of my [my child’s] recovery.			
f. I [my child] generally accomplishes what I [they] set out to do.			

If your program does not require Section G and this is a …

1. BASELINE ASSESSMENT, stop now – the interview is completed

2. REASSESSMENT interview – go to Section H.

3. CLINICAL DISCHARGE interview assessments go to Section H.

IF YOUR PROGRAM DOES REQUIRE SECTION G, and this is a …

1. BASELINE interview – go to Section G and then stop. The interview has been completed.

2. REASSESSMENT interview: go to Section G, and then to Section H.

3. CLINICAL DISCHARGE interview – go to Section G, and then Section H.

G. PROGRAM-SPECIFIC QUESTIONS

You are not responsible for collecting data on all Section G questions. Your GPO will provide guidance on which specific Section G questions you are to complete. If you have any questions, please contact your GPO.

G1. PROGRAM-SPECIFIC QUESTIONS: ASSISTED OUTPATIENT TREATMENT

Question 1 should be asked of the client/consumer at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.

1. In the past 30 days, have you taken your psychiatric medication(s) as prescribed to you?

• Yes

• No

• Refused

• Not applicable

Question 2 should be answered by grantee staff at REASSESSMENT and CLINICAL DISCHARGE.

2. In the past 30 days, have you followed your treatment plan?

• Yes

• No

• Refused

• Not applicable

If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Sections H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.

G2. PROGRAM-SPECIFIC QUESTIONS: LAW ENFORCEMENT AND BEHAVIORAL HEALTH PARNTERSHIPS FOR EARLY DIVERSION

Questions 1 and 2 should be answered by grantee at

BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.

1. Was the consumer referred to mental health services?

YES NO

 

1. [IF YES] Did they receive mental health services?

YES NO OTHER

 

2. Was the consumer referred to substance use disorder services?

YES NO

 

1. [IF YES] Did they receive substance use disorder services?

YES NO OTHER

 

Question 3 should be answered by the client/consumer only at REASSESSMENT and CLINICAL DISCHARGE.

3. Has this program helped you avoid further contact with the police and criminal justice system?

• Yes

• No

• No response

• Refused

If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.

G3. PROGRAM-SPECIFIC QUESTIONS: PROMOTING THE INTEGRATION OF PRIMARY AND BEHAVIORAL HEALTH CARE

Questions should be answered by the client/consumer at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.

1. In the past 30 days, have you ….	Yes	No	Refused
a. Been to the emergency room for a physical healthcare problem?	|		
b. Been hospitalized overnight for a physical healthcare problem?			

[PROGRAM-SPECIFIC HEALTH ITEMS ARE REPORTED BY THE GRANTEE ABOUT THE CONSUMER.]

Program-Specific Health Items

1. Health measurements (Report Quarterly)

   a.	Systolic blood pressure		mmHg
   b.	Diastolic blood pressure		mmHg
   c.	Weight		kg
   d.	Height		cm
   f.	Breath CO for smoking status		ppm

2. Blood test results (Report at Baseline, Reassessment, & Clinical Discharge). For b or c, please choose one only.

a. Date of blood draw: |____|____| / |____|____| / |____|____|____|____|
MONTH DAY YEAR

b.	Fasting plasma glucose		mg/dL
c.	HgBA1c		%
d.	Total Cholesterol		mg/dL
e.	LDL Cholesterol		mg/dL

If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.

G4. PROGRAM-SPECIFIC QUESTIONS: MINORITY AIDS – SERVICE INTEGRATION

Questions should be asked by grantee staff at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE

1a. Did the program provide an HIV test?

• Yes

• No [SKIP TO G1b.]

• REFUSED [SKIP TO G1b.]

• DON’T KNOW [SKIP TO G1b.]

[IF YES] What was the result?

• Positive

• Negative [SKIP TO G1b.]

• Indeterminate [SKIP TO G1b.]

• REFUSED [SKIP TO G1b.]

• DON’T KNOW [SKIP TO G1b.]

[IF CONSUMER SCREENED POSITIVE] Were you connected to HIV treatment services?

• Yes

• No

• REFUSED

• DON’T KNOW

1b. Did the program provide a Hepatitis B (HBV) test?

• Yes

• No [SKIP TO G1c.]

• REFUSED [SKIP TO G1c.]

• DON’T KNOW [SKIP TO G1c.]

[IF YES] What was the result?

• Positive

• Negative [SKIP TO G1c.]

• Indeterminate [SKIP TO G1c.]

• REFUSED [SKIP TO G1c.]

• DON’T KNOW [SKIP TO G1c.]

[IF CONSUMER SCREENED POSITIVE] Were you connected to HBV treatment services?

• Yes

• No

• REFUSED

• DON’T KNOW

1c. Did the program provide a Hepatitis C (HCV) test?

• Yes

• No [SKIP TO G2a.]

• REFUSED [SKIP TO G2a.]

• DON’T KNOW [SKIP TO G2a.]

[IF YES] What was the result?

• Positive

• Negative [SKIP TO G2a.]

• Indeterminate [SKIP TO G2a.]

• REFUSED [SKIP TO G2a.]

• DON’T KNOW [SKIP TO G2a.]

[IF CONSUMER SCREENED POSITIVE] Were you connected to HCV treatment services?

• Yes

• No

• REFUSED

• DON’T KNOW

2a. [If HIV STATUS IS POSITIVE] Did you receive a referral form from [INSERT GRANTEE NAME] to medical care?

• Yes

• No

• REFUSED

• DON’T KNOW

2b. Have you been prescribed an Antiretroviral Medication (ART)?

• Yes

• No

• REFUSED

• DON’T KNOW

[FOR CONSUMERS WHO REPORT BEING PRESCRIBED AN ART] In the past 30 days, how often have you taken your ART as prescribed to you?

• Always

• Usually

• Sometimes

• Rarely

• Never

• Refused

• DON’T KNOW

• NOT APPLICABLE

If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.

[IF THE PRESCRIPTION WAS GIVEN FOR THE FIRST TIME AT THIS APPOINTMENT, SELECT NOT APPLICABLE.]

G5. PROGRAM-SPECIFIC QUESTIONS: HEALTHY TRANSITIONS

Questions should be answered by grantee staff at BASELINE, REASSESSMENT and CLINICAL DISCHARGE.

1. Was the consumer referred to mental health services?

YES NO

 

1. [IF YES] Did they receive mental health services?

YES NO OTHER

 

2. Was the consumer referred to substance use disorder services?

YES NO

 

1. [IF YES] Did they receive substance use disorder services?

YES NO OTHER

 

If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.

G6. PROGRAM-SPECIFIC QUESTIONS: ASSERTIVE COMMUNITY TREATMENT

Questions 1 and 2 should be answered by the consumer/client at REASSESSMENT and CLINICAL DISCHARGE

1. How often does a member of your team interact with you?

• At least daily

• At least weekly

• At least monthly

• Never

• REFUSED

• DON’T KNOW

2. If I need to talk with someone on my team, I know who to call.

• Yes

• No

• Refused

• Not applicable

If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.

G7. PROGRAM-SPECIFIC QUESTIONS: CLINICAL HIGH RISK FOR PSYCHOSIS

Question 1 should be answered by grantee staff at REASSESSMENT and CLINICAL DISCHARGE.

1. Has the consumer experienced an episode of psychosis since their last interview?

• Yes

• No

• DON’T KNOW

a. [IF YES] Please indicate the approximate date that the consumer initially experienced psychosis.

|___|___| / |___|___|___|___|
MONTH YEAR

b. [IF YES] Was the consumer referred to services?

• Yes

• No

• DON’T KNOW

[IF CONSUMER WAS REFERRED] Please indicate the date that the consumer received services/treatment.

|___|___| / |___|___|___|___| DON’T KNOW
MONTH YEAR 

If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.

G8 PROGRAM-SPECIFIC QUESTIONS: CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS

Program specific health items are reported by Grantee Staff about the client/consumer at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.

1. During the past 30 days, did the client/consumer receive the following services?

   • Crisis mental health services _____ Yes _____ No

   • Screening, assessment, diagnosis _____ Yes _____ No

   • Patient-centered treatment planning _____ Yes _____ No

   • Outpatient mental health services _____ Yes _____ No

   • Physical health screening/monitoring _____ Yes _____ No

   • Targeted case management _____ Yes _____ No

   • Psychiatric rehabilitation services _____ Yes _____ No

   • Peer support services _____ Yes _____ No

   • Family psychoeducation and support _____ Yes _____ No

   • Services for veterans and military members _____ Yes _____ No

2. Health measurements: (Report quarterly)

a.	Systolic blood pressure		mmHg
b.	Diastolic blood pressure		mmHg
c.	Weight		kg
d.	Height		cm

If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.

G9 PROGRAM-SPECIFIC QUESTIONS: NATIONAL CHILD TRAUMATIC STRESS INITIATIVE – CATEGORY 3

Questions should be answered by the client/consumer or caregiver REASSESSMENT,

and CLINICAL DISCHARGE.

Read each statement below to the client/consumer or caregiver and note the responses.

STATEMENT
	Yes	No	No response	Not applicable
1. As a result of treatment and services received, my [my child’s] trauma and/or loss experiences were identified and addressed.				
2. As a result of treatment and services received for trauma and/or loss experiences, my [my child’s] problem behaviors/symptoms have decreased.				

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.

H. SERVICES RECEIVED AND CLINICAL DISCHARGE STATUS

Question 1 is reported by Grantee Staff about the client/consumer at REASSESSMENT and CLINICAL DISCHARGE only.

1. On what date did the consumer last receive services?

|___|___| / |___|___|___|___|

MONTH YEAR

Identify all the services your grant project provided to the client/consumer during their participation in the program. This includes grant-funded and non-grant funded services.

Core Services	Provided		UNKNOWN	SERVICE NOT AVAILABLE
	Yes	No
Screening				
Assessment				
Treatment Planning or Review				
Psychopharmacological Services				
Mental Health Services				
Co-occurring Services				
Case Management				
Trauma-specific Services				
Was the consumer referred to another provider for any of the above core services?				

Support Services	Provided		UNKNOWN	SERVICE NOT AVAILABLE
	Yes	No
Medical Care				
Employment Services				
Family Services				
Child Care				
Transportation				
Education Services				
Housing Support				
Social Recreational Activities				
Consumer-Operated Services				
HIV Testing				
Was the consumer referred to another provider for any of the above support services?				

Questions 2 and 3 are reported by Grantee Staff about the client/consumer at CLINICAL DISCHARGE only

2. On what date was the consumer discharged?

|___|___| / |___|___|___|___|
MONTH YEAR

3. What is the consumer’s discharge status?

 Mutually agreed cessation of treatment

• Withdrew from/refused treatment

 No contact within 90 days of last encounter

 Clinically referred out

 Death

 Other (Specify)

Page 1 of 49