Form Approved

OMB No. 0930-0208

Expiration Date 01/31/2007

**CSAT GPRA Client Outcome**

**Measures for Discretionary Programs**

Public reporting burden for this collection of information is estimated
to average 20 minutes per response 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/participant intake or
followup, 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 7-1045, 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 0930-0208.

A. RECORD MANAGEMENT

**Client ID**
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

**Client Type:**

-   Treatment client

-   Client in recovery

**Contract/Grant ID**
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

Interview Type *\[CIRCLE ONLY ONE TYPE.\]*

Intake \[GO TO INTERVIEW DATE\]

6 month follow-up **→ → →** Did you conduct a follow-up interview?
 Yes   No

***\[IF NO, GO DIRECTLY TO SECTION I.\]***

3 month follow-up ***\[ADOLESCENT PORTFOLIO ONLY\]* →**  

Did you conduct a follow-up interview?  Yes   No ***\[IF NO, GO DIRECTLY
TO SECTION I.\]***

Discharge **→ → →** Did you conduct a discharge interview?  Yes   No

***\[IF NO, GO DIRECTLY TO SECTION J.\]***

**Interview Date** \|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

Month Day Year

*FOR SBIRT GRANTS ONLY: REPORTED ONLY AT INTAKE/BASELINE*

How did the client screen?   Negative   Positive

What was his/her screening score? AUDIT = \|\_\_\_\_\|\_\_\_\_\|

CAGE = \|\_\_\_\_\|\_\_\_\_\|

DAST = \|\_\_\_\_\|\_\_\_\_\|

DAST-10 = \|\_\_\_\_\|\_\_\_\_\|

NIAAA Guide = \|\_\_\_\_\|\_\_\_\_\|

Other (Specify) \_\_\_\_\_\_\_\_\_\_\_\_\_ = \|\_\_\_\_\|\_\_\_\_\|

Was he/she willing to continue his/her participation in the SBIRT
program?   Yes   No

*\[FOLLOW-UP AND DISCHARGE INTERVIEWS: SKIP TO SECTION B.\]*

A. RECORD MANAGEMENT (Continued)

PLANNED SERVICES \[*REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT
INTAKE/BASELINE\]*

**Identify the services you plan to provide to the client during the
client's course of treatment/recovery. *\[CIRCLE 'Y' FOR YES OR 'N' FOR
NO FOR EACH ONE.\]***

**Modality Yes No**

***\[SELECT AT LEAST ONE MODALITY.\]***

1\. Case Management Y N

2\. Day Treatment Y N

3\. Inpatient/Hospital (Other Than Detox) Y N

4\. Outpatient Y N

5\. Outreach Y N

6\. Intensive Outpatient Y N

7\. Methadone Y N

8\. Residential/Rehabilitation Y N

9\. Detoxification (Select Only One)

> A. Hospital Inpatient Y N
>
> B. Free Standing Residential Y N
>
> C. Ambulatory Detoxification Y N

10\. After Care Y N

11\. Recovery Support Y N

12\. Other (Specify) Y N

**Treatment Services Yes No**

***\[SBIRT GRANTS: You must circle 'Y' for at least one of the Treatment
Services numbered 1 through 4.\]***

1\. Screening Y N

2\. Brief Intervention Y N

3\. Brief Treatment Y N

4\. Referral to Treatment Y N

5\. Assessment Y N

6\. Treatment/Recovery Planning Y N

7\. Individual Counseling Y N

8\. Group Counseling Y N

9\. Family/Marriage Counseling Y N

10\. Co-Occurring Treatment/

‌Recovery Services Y N

11\. Pharmacological Interventions Y N

12\. HIV/AIDS Counseling Y N

13\. Other Clinical Services Y N

(Specify)

**Case Management Services Yes No**

1\. Family Services (Including Marriage Education, Parenting, Child
Development Services) Y N

2\. Child Care Y N

3\. Employment Service

> A. Pre-Employment Y N
>
> B. Employment Coaching Y N

4\. Individual Services Coordination Y N

5\. Transportation Y N

6\. HIV/AIDS Service Y N

7\. Supportive Transitional Drug-Free Housing Services Y N

8\. Other Case Management Services Y N

(Specify)

**Medical Services Yes No**

1\. Medical Care Y N

2\. Alcohol/Drug Testing Y N

3\. HIV/AIDS Medical Support & Testing Y N

4\. Other Medical Services Y N

(Specify)

**After Care Services Yes No**

1\. Continuing Care Y N

2\. Relapse Prevention Y N

3\. Recovery Coaching Y N

4\. Self-Help and Support Groups Y N

5\. Spiritual Support Y N

6\. Other After Care Services Y N

(Specify)

**Education Services Yes No**

1\. Substance Abuse Education Y N

2\. HIV/AIDS Education Y N

3\. Other Education Services Y N

(Specify)

**Peer-To-Peer Recovery Support Services Yes No**

1\. Peer Coaching or Mentoring Y N

2\. Housing Support Y N

3\. Alcohol- and Drug-Free Social Activities Y N

4\. Information and Referral Y N

5\. Other Peer-to-Peer Recovery Support Services Y N

(Specify)

A. RECORD MANAGEMENT - DEMOGRAPHICS *\[ASKED ONLY AT INTAKE/BASELINE\]*

**1. What is your gender?**

Male

Female

Transgender

Other (Specify)

Refused

**2. Are you Hispanic or Latino?**

Yes

No

Refused

***\[IF YES\]* What ethnic group do you consider yourself? Please answer
yes or no for each of the following. You may say yes to more than one.**

**Yes No Refused**

Central American Y N Refused

Cuban Y N Refused

Dominican Y N Refused

Mexican Y N Refused

Puerto Rican Y N Refused

South American Y N Refused

Other Y N Refused *\[IF YES, SPECIFY BELOW\]*

(Specify)

**3. What is your race? Please answer yes or no for each of the
following. You may say yes to more than one.**

**Yes No Refused**

Black or African American Y N Refused

Asian Y N Refused

Native Hawaiian or other Pacific Islander Y N Refused

Alaska Native Y N Refused

White Y N Refused

American Indian Y N Refused

**4. What is your date of birth?\***

\|\_\_\_\_\|\_\_\_\_\| / [\|\_\_\_\_\|\_\_\_\_\|]{.mark} /

Month Day

\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

Year

 Refused

***\*The system will only save Month and Year**. DAY IS NOT SAVED TO
MAINTAIN CONFIDENTIALITY.*

B. DRUG AND ALCOHOL USE

+------------------------------------------+----------------+---------+
|                                          | **Number\      | **DON'T |
|                                          | of Days        | KNOW**  |
|                                          | REFUSED**      |         |
+------------------------------------------+----------------+---------+
| **1. During the past 30 days how many    |                | []      |
| days have you used the following:**      |                | {.mark} |
+------------------------------------------+----------------+---------+
| a\. Any alcohol ***\[IF ZERO, SKIP TO    | \|\_\_\_       |         |
| ITEM B1c.\]***                           | \_\|\_\_\_\_\| |         |
+------------------------------------------+----------------+---------+
| b1. Alcohol to intoxication (5+ drinks   | \|\_\_\_       |         |
| in one sitting)                          | \_\|\_\_\_\_\| |         |
+------------------------------------------+----------------+---------+
| b2. Alcohol to intoxication (4 or fewer  | \|\_\_\_       |         |
| drinks in one sitting and felt high)     | \_\|\_\_\_\_\| |         |
+------------------------------------------+----------------+---------+
| c\. Illegal drugs                        | \|\_\_\_       |         |
|                                          | \_\|\_\_\_\_\| |         |
+------------------------------------------+----------------+---------+
| d\. Both alcohol and drugs (on the same  | \|\_\_\_       |         |
| day)                                     | \_\|\_\_\_\_\| |         |
+------------------------------------------+----------------+---------+
| []{.mark}                                |                | []      |
|                                          |                | {.mark} |
+------------------------------------------+----------------+---------+
| **Route of Administration Types:**       | **Number\      | **      |
|                                          | of Days RF     | Route\* |
| 1\. Oral 2. Nasal 3. Smoking 4. Non-IV   | DK**           | RF DK** |
| injection 5. IV                          |                |         |
|                                          |                |         |
| \*Note the usual route. For more than    |                |         |
| one route, choose the most severe. The   |                |         |
| routes are listed from least severe (1)  |                |         |
| to most severe (5).                      |                |         |
+------------------------------------------+----------------+---------+
| **2. During the past 30 days, how many   |                |         |
| days have you used any of the            |                |         |
| following:**                             |                |         |
+------------------------------------------+----------------+---------+
| a\. Cocaine/Crack                        | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| b\. Marijuana/Hashish (Pot, Joints,      | \|\_\_\_       | \|\_\   |
| Blunts, Chronic, Weed, Mary Jane)        | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| c\. Opiates:                             |                |         |
+------------------------------------------+----------------+---------+
| 1\. Heroin (Smack, H, Junk, Skag)        | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 2\. Morphine                             | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 3\. Diluadid                             | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 4\. Demerol                              | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 5\. Percocet                             | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 6\. Darvon                               | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 7\. Codeine                              | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 8\. Tylenol 2,3,4                        | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 9\. Oxycontin/Oxycodone                  | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| d\. Non-prescription methadone           | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| e\. Hallucinogens/psychedelics, PCP      | \|\_\_\_       | \|\_\   |
| (Angel Dust, Ozone, Wack, Rocket Fuel)   | \_\|\_\_\_\_\| | _\_\_\| |
| MDMA (Ecstasy, XTC, X, Adam), LSD (Acid, |                |         |
| Boomers, Yellow Sunshine), Mushrooms or  |                |         |
| Mescaline                                |                |         |
+------------------------------------------+----------------+---------+
| f\. Methamphetamine or other             | \|\_\_\_       | \|\_\   |
| amphetamines (Meth, Uppers, Speed, Ice,  | \_\|\_\_\_\_\| | _\_\_\| |
| Chalk, Crystal, Glass, Fire, Crank)      |                |         |
+------------------------------------------+----------------+---------+

B. DRUG AND ALCOHOL USE (Continued)

+------------------------------------------+----------------+---------+
| **Route of Administration Types:**       |                |         |
|                                          |                |         |
| 1\. Oral 2. Nasal 3. Smoking 4. Non-IV   |                |         |
| injection 5. IV                          |                |         |
|                                          |                |         |
| \*Note the usual route. For more than    |                |         |
| one route, choose the most severe. The   |                |         |
| routes are listed from least severe (1)  |                |         |
| to most severe (5).                      |                |         |
+------------------------------------------+----------------+---------+
| **2. During the past 30 days, how many   | **Number\      | **      |
| days have you used any of the            | of Days RF     | Route\* |
| following:**                             | DK**           | RF DK** |
+------------------------------------------+----------------+---------+
| g\. 1. Benzodiazepines: Diazepam         | \|\_\_\_       | \|\_\   |
| (Valium); Alprazolam (Xanax); Triazolam  | \_\|\_\_\_\_\| | _\_\_\| |
| (Halcion); and Estasolam (Prosom and\    |                |         |
| Rohypnol--also known as roofies, roche,  |                |         |
| and cope)                                |                |         |
+------------------------------------------+----------------+---------+
| 2\. Barbiturates: Mephobarbital          | \|\_\_\_       | \|\_\   |
| (Mebacut); and pentobarbital sodium      | \_\|\_\_\_\_\| | _\_\_\| |
| (Nembutal)                               |                |         |
+------------------------------------------+----------------+---------+
| 3\. Non-prescription GHB (known as       | \|\_\_\_       | \|\_\   |
| Grievous Bodily Harm; Liquid Ecstasy;    | \_\|\_\_\_\_\| | _\_\_\| |
| and Georgia Home Boy)                    |                |         |
+------------------------------------------+----------------+---------+
| 4\. Ketamine (known as Special K or      | \|\_\_\_       | \|\_\   |
| Vitamin K)                               | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| 5\. Other tranquilizers, downers,        | \|\_\_\_       | \|\_\   |
| sedatives or hypnotics                   | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| h\. Inhalants (poppers, snappers, rush,  | \|\_\_\_       | \|\_\   |
| whippets)                                | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+
| i\. Other illegal drugs (Specify)        | \|\_\_\_       | \|\_\   |
|                                          | \_\|\_\_\_\_\| | _\_\_\| |
+------------------------------------------+----------------+---------+

**3. In the past 30 days have you injected drugs?**

YES

NO

Refused

Don't know

***\[IF NO, REFUSED, OR DON'T KNOW GO TO SECTION C.\]***

**4. In the past 30 days, how often did you use a syringe/needle,
cooker, cotton or water that someone else used?**

Always

More than half the time

Half the time

Less than half the time

Never

Refused

Don't know

C. FAMILY AND LIVING CONDITIONS

**1. In the past 30 days, where have you been living most of the time?
*\[DO NOT READ RESPONSE OPTIONS TO CLIENT.\]***

Shelter (safe havens, transitional living center \[TLC\], low demand
facilities, reception centers, other temporary day or evening facility)

Street/outdoors (sidewalk, doorway, park, public or abandoned building)

Institution (hospital, nursing home, jail/prison)

Housed:

Own/rent apartment, room, or house

Someone else's apartment, room or house

Halfway house

Residential treatment

Other housed (Specify)

Refused

Don't know

**2. 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

Not Applicable

Refused

Don't know

**3. 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

Not Applicable

Refused

Don't know

C. FAMILY AND LIVING CONDITIONS (Continued)

**4. 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

Not Applicable

Refused

Don't know

**5. *\[IF NOT MALE,\]* Are you currently pregnant?**

Yes

No

Refused

Don't know

**6. Do you have children?**

Yes

No

Refused

Don't know

***\[IF NO, REFUSED, OR DON'T KNOW GO TO SECTION D.\]***

**a. How many children do you have?**

\|\_\_\_\_\|\_\_\_\_\|   Refused   Don't know

**b. Are any of your children living with someone else due to a child
protection court order?**

Yes

No

Refused

Don't know

***\[IF NO, REFUSED, OR DON'T KNOW GO TO SECTION D.\]***

**c. *\[IF YES,\]* How many of your children are living with someone
else due to a child protection court order?**

\|\_\_\_\_\|\_\_\_\_\|   Refused   Don't know

C. FAMILY AND LIVING CONDITIONS (Continued)

**d. For how many of your children have you lost parental rights? *\[THE
CLIENT'S PARENTAL RIGHTS WERE TERMINATED.\]***

\|\_\_\_\_\|\_\_\_\_\|   Refused   Don't know

D. EDUCATION, EMPLOYMENT, AND INCOME

**1. Are you currently enrolled in school or a job training program?
*\[IF ENROLLED,\]* Is that full time or part time?**

Not enrolled

Enrolled, full time

Enrolled, part time

Other (Specify)

Refused

Don't know

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

NEVER ATTENDED

1^ST^ GRADE

2^ND^ GRADE

3^RD^ GRADE

4^TH^ GRADE

5^TH^ GRADE

6^TH^ GRADE

-   7^TH^ GRADE

-   8^TH^ GRADE

-   9^TH^ GRADE

-   10^TH^ GRADE

-   11^TH^ GRADE

-   12^TH^ GRADE/HIGH SCHOOL DIPLOMA/EQUIVALENT

-   COLLEGE OR UNIVERSITY/1^st^ YEAR COMPLETED

-   COLLEGE OR UNIVERSITY/2^nd^ YEAR COMPLETED/ASSOCIATES DEGREE (AA,
    AS)

-   COLLEGE OR UNIVERSITY/3^rd^ YEAR COMPLETED

-   BACHELOR'S DEGREE (BA, BS) OR HIGHER

-   VOC/TECH PROGRAM AFTER HIGH SCHOOL BUT NO VOC/TECH DIPLOMA

-   VOC/TECH DIPLOMA AFTER HIGH SCHOOL

Refused

Don't know

D. EDUCATION, EMPLOYMENT, AND INCOME (Continued)

**3. Are you currently employed? *\[CLARIFY BY FOCUSING ON STATUS DURING
MOST OF THE PREVIOUS WEEK, DETERMINING WHETHER CLIENT WORKED AT ALL OR
HAD A REGULAR JOB BUT WAS OFF WORK.\]***

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

Employed part time

Unemployed, looking for work

Unemployed, disabled

Unemployed, volunteer work

Unemployed, retired

Unemployed, not looking for work

Other (Specify)

Refused

Don't know

**4. Approximately, how much money did YOU receive (pre-tax individual
income) in the past 30 days from...**

**RF DK**

a\. Wages \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|      

b\. Public assistance \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|  

c\. Retirement \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|      

d\. Disability \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|     

e\. Non-legal income \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|     

f\. Family and/or friends \$ \|\_\_\|\_\_\|\_\_\| ,
\|\_\_\|\_\_\|\_\_\|     

g\. Other (Specify) \$ \|\_\_\|\_\_\|\_\_\| , \|\_\_\|\_\_\|\_\_\|      

E. CRIME AND CRIMINAL JUSTICE STATUS

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

\|\_\_\_\_\|\_\_\_\_\| times   Refused   Don't know

***\[IF NO ARRESTS, GO TO ITEM E3.\]***

**2. In the past 30 days, how many times have you been arrested for
drug-related offenses?**

\|\_\_\_\_\|\_\_\_\_\| times   Refused   Don't know

**3. In the past 30 days, how many nights have you spent in
jail/prison?**

\|\_\_\_\_\|\_\_\_\_\| nights   Refused   Don't know

E. CRIME AND CRIMINAL JUSTICE STATUS (Continued)

**4. In the past 30 days, how many times have you committed a crime?
*\[CHECK NUMBER OF DAYS USED ILLEGAL DRUGS IN ITEM B1c ON PAGE 4. ANSWER
HERE IN E4 MUST BE EQUAL TO OR GREATER THAN NUMBER IN B1c BECAUSE USING
ILLEGAL DRUGS IS A CRIME.\]***

\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\| times   Refused   Don't know

**5. Are you currently awaiting charges, trial, or sentencing?**

Yes

No

Refused

Don't know

**6. Are you currently on parole or probation?**

Yes

No

Refused

Don't know

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY

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

Excellent

Very good

Good

Fair

Poor

Refused

Don't know

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY (Cont.)

**2. During the past 30 days, did you receive:**

+---------------------------------+----+----------------+----+---+----+
| **a. Inpatient Treatment for:** |    | ***\[IF        |    |   |    |
|                                 |    | YES\]***       |    |   |    |
+---------------------------------+----+----------------+----+---+----+
|                                 | *  | **Altogether\  | ** | * | ** |
|                                 | *Y | for how many   | NO | * | DK |
|                                 | ES | nights**       | ** | R | ** |
|                                 | ** |                |    | F |    |
|                                 |    |                |    | * |    |
|                                 |    |                |    | * |    |
+---------------------------------+----+----------------+----+---+----+
| > i\. Physical complaint        |    | nights         |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > ii\. Mental or emotional      |    | nights         |    |   |    |
| > difficulties                  |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > iii\. Alcohol or substance    |    | nights         |    |   |    |
| > abuse                         |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+

+---------------------------------+----+----------------+----+---+----+
| **b. Outpatient Treatment       |    | ***\[IF        |    |   |    |
| for:**                          |    | YES\]***       |    |   |    |
+---------------------------------+----+----------------+----+---+----+
|                                 | *  | **Altogether\  | ** | * | ** |
|                                 | *Y | for how many   | NO | * | DK |
|                                 | ES | times**        | ** | R | ** |
|                                 | ** |                |    | F |    |
|                                 |    |                |    | * |    |
|                                 |    |                |    | * |    |
+---------------------------------+----+----------------+----+---+----+
| > i\. Physical complaint        |    | times          |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > ii\. Mental or emotional      |    | times          |    |   |    |
| > difficulties                  |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > iii\. Alcohol or substance    |    | times          |    |   |    |
| > abuse                         |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+

+---------------------------------+----+----------------+----+---+----+
| **c. Emergency Room Treatment   |    | ***\[IF        |    |   |    |
| for:**                          |    | YES\]***       |    |   |    |
+---------------------------------+----+----------------+----+---+----+
|                                 | *  | **Altogether\  | ** | * | ** |
|                                 | *Y | for how many   | NO | * | DK |
|                                 | ES | times**        | ** | R | ** |
|                                 | ** |                |    | F |    |
|                                 |    |                |    | * |    |
|                                 |    |                |    | * |    |
+---------------------------------+----+----------------+----+---+----+
| > i\. Physical complaint        |    | times          |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > ii\. Mental or emotional      |    | times          |    |   |    |
| > difficulties                  |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+
| > iii\. Alcohol or substance    |    | times          |    |   |    |
| > abuse                         |    |                |    |   |    |
+---------------------------------+----+----------------+----+---+----+

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY (Cont.)

**3. During the past 30 days, did you engage in sexual activity?**

Yes

No **→ *\[GO TO F4.\]***

Not permitted to ask **→ *\[GO TO F4.\]***

Refused **→ *\[GO TO F4.\]***

Don't know **→ *\[GO TO F4.\]***

***\[IF YES\]* Altogether, how many:**

+-----------------------------------------------+-------------+---+----+
|                                               | *           | * | ** |
|                                               | *Contacts** | * | DK |
|                                               |             | R | ** |
|                                               |             | F |    |
|                                               |             | * |    |
|                                               |             | * |    |
+-----------------------------------------------+-------------+---+----+
| a\. Sexual contacts (vaginal, oral, or anal)  | \|\_\_\_\_  |   |    |
| did you have?                                 | \|\_\_\_\_\ |   |    |
|                                               | |\_\_\_\_\| |   |    |
+-----------------------------------------------+-------------+---+----+
| b\. Unprotected sexual contacts did you have? | \|\_\_\_\_  |   |    |
| ***\[IF ZERO, GO TO F4.\]***                  | \|\_\_\_\_\ |   |    |
|                                               | |\_\_\_\_\| |   |    |
+-----------------------------------------------+-------------+---+----+
| c\. Unprotected sexual contacts were with an  |             |   |    |
| individual who is or was:                     |             |   |    |
+-----------------------------------------------+-------------+---+----+
| > 1\. HIV positive or has AIDS                | \|\_\_\_\_  |   |    |
|                                               | \|\_\_\_\_\ |   |    |
|                                               | |\_\_\_\_\| |   |    |
+-----------------------------------------------+-------------+---+----+
| > 2\. An injection drug user                  | \|\_\_\_\_  |   |    |
|                                               | \|\_\_\_\_\ |   |    |
|                                               | |\_\_\_\_\| |   |    |
+-----------------------------------------------+-------------+---+----+
| > 3\. High on some substance                  | \|\_\_\_\_  |   |    |
|                                               | \|\_\_\_\_\ |   |    |
|                                               | |\_\_\_\_\| |   |    |
+-----------------------------------------------+-------------+---+----+

**4. In the past 30 days, not due to your use of alcohol or drugs, how
many days have you:**

  ----------------------------------------------- ------------------------ -------- --------
                                                  **Days**                 **RF**   **DK**

  a\. Experienced serious depression              \|\_\_\_\_\|\_\_\_\_\|            

  b\. Experienced serious anxiety or tension      \|\_\_\_\_\|\_\_\_\_\|            

  c\. Experienced hallucinations                  \|\_\_\_\_\|\_\_\_\_\|            

  d\. Experienced trouble understanding,          \|\_\_\_\_\|\_\_\_\_\|            
  concentrating, or remembering                                                     

  e\. Experienced trouble controlling violent     \|\_\_\_\_\|\_\_\_\_\|            
  behavior                                                                          

  f\. Attempted suicide                           \|\_\_\_\_\|\_\_\_\_\|            

  g\. Been prescribed medication for              \|\_\_\_\_\|\_\_\_\_\|            
  psychological/emotional problem                                                   
  ----------------------------------------------- ------------------------ -------- --------

***\[IF CLIENT REPORTS ZERO DAYS TO ALL ITEMS IN QUESTION 4, SKIP TO
SECTION G.\]***

**5. How much have you been bothered by these psychological or emotional
problems in the past 30 days?**

Not at all

Slightly

Moderately

Considerably

Extremely

Refused

Don't know

G. SOCIAL CONNECTEDNESS

**1. In the past 30 days, did you attend 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  ***\[IF YES\]*** Specify how many times
[   ]{.underline}  Refused   Don't know

No

Refused

Don't know

**2. In the past 30 days, did you attend any religious/faith affiliated
recovery self-help groups?**

Yes  ***\[IF YES\]*** Specify how many times
[   ]{.underline}  Refused   Don't know

No

Refused

Don't know

**3. In the past 30 days, did you attend meetings of organizations that
support recovery other than the organizations described above?**

Yes  ***\[IF YES\]*** Specify how many times
[   ]{.underline}  Refused   Don't know

No

Refused

Don't know

**4. In the past 30 days, did you have interaction with family and/or
friends that are supportive of your recovery?**

Yes

No

Refused

Don't know

5.  **To whom do you turn when you are having trouble? *\[SELECT ONLY
    ONE.\]***

No One

Clergy Member

Family Member

Friends

REFUSED

DoN'T KNOW

Other Specify:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***\[IF THIS IS AN INTAKE/BASELINE INTERVIEW, STOP NOW, THE INTERVIEW IS
COMPLETE. REMEMBER TO FILL IN PLANNED SERVICES ON PAGE 2.\]***

I. FOLLOW-UP STATUS

\[*REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT FOLLOW-UP\]*

**1. What is the follow-up status of the client? *\[THIS IS A REQUIRED
FIELD: NA, REFUSED, DON'T KNOW, AND MISSING WILL NOT BE ACCEPTED\]. ***

01 = Deceased at time of due date

11 = Completed interview within specified window

12 = Completed interview outside specified window

21 = Located, but refused, unspecified

22 = Located, but unable to gain institutional access

23 = Located, but otherwise unable to gain access

24 = Located, but withdrawn from project

31 = Unable to locate, moved

32 = Unable to locate, other (SPECIFY)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2. Is the client still receiving services from your program?**

Yes

No

***\[IF THIS IS A FOLLOW-UP INTERVIEW STOP NOW, THE INTERVIEW IS
COMPLETE.\]***

J. DISCHARGE STATUS

*\[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE\]*

**1. On what date was the client discharged?**

\|\_\_\_\_\|\_\_\_\_\| / \|\_\_\_\_\|\_\_\_\_\| /
\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|\_\_\_\_\|

Month Day Year

**2. What is the client's discharge status?**

01 = Completion/Graduate

02 = Termination

If the client was terminated, what was the reason for termination?
\[*Select one response*.\]

01 = Left on own against staff advice with satisfactory progress

02 = Left on own against staff advice without satisfactory progress

03 = Involuntarily discharged due to nonparticipation

04 = Involuntarily discharged due to violation of rules

05 = Referred to another program or other services with satisfactory
progress

06 = Referred to another program or other services with unsatisfactory
progress

07 = Incarcerated due to offense committed while in treatment/recovery
with satisfactory progress

08 = Incarcerated due to offense committed while in treatment/recovery
with unsatisfactory progress

09 = Incarcerated due to old warrant or charged from before entering
treatment/recovery with satisfactory progress

10 = Incarcerated due to old warrant or charged from before entering
treatment/recovery with unsatisfactory progress

11 = Transferred to another facility for health reasons

12 = Death

13 = Other (Specify)

K. SERVICES RECEIVED

*\[REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE\]*

**Identify the number of DAYS of services provided to the client during
the client's course of treatment**/‌**recovery. *\[ENTER ZERO IF NO
SERVICES PROVIDED. YOU SHOULD HAVE AT LEAST ONE DAY FOR MODALITY.\]***

**Modality Days**

1\. Case Management \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. Day Treatment \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Inpatient/‌Hospital (Other Than Detox) \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Outpatient \|\_\_\_\|\_\_\_\|\_\_\_\|

5\. Outreach \|\_\_\_\|\_\_\_\|\_\_\_\|

6\. Intensive Outpatient \|\_\_\_\|\_\_\_\|\_\_\_\|

7\. Methadone \|\_\_\_\|\_\_\_\|\_\_\_\|

8\. Residential/Rehabilitation \|\_\_\_\|\_\_\_\|\_\_\_\|

9\. Detoxification (Select Only One)

> A. Hospital Inpatient \|\_\_\_\|\_\_\_\|\_\_\_\|
>
> B. Free Standing Residential \|\_\_\_\|\_\_\_\|\_\_\_\|
>
> C. Ambulatory Detoxification \|\_\_\_\|\_\_\_\|\_\_\_\|

10\. After Care \|\_\_\_\|\_\_\_\|\_\_\_\|

11\. Recovery Support \|\_\_\_\|\_\_\_\|\_\_\_\|

12\. Other (Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**Identify the number of SESSIONS provided to the client during the
client's course of treatment**/‌**recovery. *\[ENTER ZERO IF NO SERVICES
PROVIDED.\]***

**Treatment Services Sessions**

***\[SBIRT GRANTS: You must have at least one session for one of the
Treatment Services numbered 1 through 4.\]***

1\. Screening \|\_\_\_\|\_\_\_\|\_\_\_\|

2 Brief Intervention \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Brief Treatment \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Referral to Treatment \|\_\_\_\|\_\_\_\|\_\_\_\|

5\. Assessment \|\_\_\_\|\_\_\_\|\_\_\_\|

6\. Treatment/Recovery Planning \|\_\_\_\|\_\_\_\|\_\_\_\|

7\. Individual Counseling \|\_\_\_\|\_\_\_\|\_\_\_\|

8\. Group Counseling \|\_\_\_\|\_\_\_\|\_\_\_\|

9\. Family/Marriage Counseling \|\_\_\_\|\_\_\_\|\_\_\_\|

10\. Co-Occurring Treatment/‌Recovery Services \|\_\_\_\|\_\_\_\|\_\_\_\|

11\. Pharmacological Interventions \|\_\_\_\|\_\_\_\|\_\_\_\|

12\. HIV/AIDS Counseling \|\_\_\_\|\_\_\_\|\_\_\_\|

13\. Other Clinical Services\
(Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**Case Management Services Sessions**

1\. Family Services (Including Marriage Education, Parenting, Child
Development Services) \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. Child Care \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Employment Service

> A. Pre-Employment \|\_\_\_\|\_\_\_\|\_\_\_\|
>
> B. Employment Coaching \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Individual Services Coordination \|\_\_\_\|\_\_\_\|\_\_\_\|

5\. Transportation \|\_\_\_\|\_\_\_\|\_\_\_\|

6\. HIV/AIDS Service \|\_\_\_\|\_\_\_\|\_\_\_\|

7\. Supportive Transitional Drug-Free Housing Services
\|\_\_\_\|\_\_\_\|\_\_\_\|

8\. Other Case Management Services (Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**Medical Services Sessions**

1\. Medical Care \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. Alcohol/Drug Testing \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. HIV/ AIDS Medical Support & Testing \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Other Medical Services\
(Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**After Care Services Sessions**

1\. Continuing Care \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. Relapse Prevention \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Recovery Coaching \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Self-Help and Support Groups \|\_\_\_\|\_\_\_\|\_\_\_\|

5\. Spiritual Support \|\_\_\_\|\_\_\_\|\_\_\_\|

6\. Other After Care Services\
(Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**Education Services Sessions**

1\. Substance Abuse Education \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. HIV/AIDS Education \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Other Education Services\
(Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|

**Peer-To-Peer Recovery Support Services Sessions**

1\. Peer Coaching or Mentoring \|\_\_\_\|\_\_\_\|\_\_\_\|

2\. Housing Support \|\_\_\_\|\_\_\_\|\_\_\_\|

3\. Alcohol- and Drug-Free Social Activities \|\_\_\_\|\_\_\_\|\_\_\_\|

4\. Information and Referral \|\_\_\_\|\_\_\_\|\_\_\_\|

5\. Other Peer-to-Peer Recovery Support Services\
(Specify) \|\_\_\_\|\_\_\_\|\_\_\_\|