CSAT_GPRA_Client_Outcome_Instrument v5.1

dig Aby‡gvw`Z

OMB bs: 0930-0208 

†gqv‡`vËx‡Y©i ZvwiL 03/31/2019

CSAT GPRA K¬v‡q›U djvdj 

† ̄^”Qvaxb Kg©m~wP ̧‡jvi Rb ̈ c`‡¶cmg~n 

(cwigvwR©Z 06/01/2012) 

hw` me ̧‡jv AvB‡Ug †Kv‡bv K¬v‡q›U/AskManYKvix‡K wR‡Ám Kiv nq, Zvn‡j GB Z_ ̈ msMa‡ni Rb ̈ RbM‡Yi cawZ‡e`‡bi  ̧i“fvi wn‡m‡e 

cawZwU Rev‡ei Rb ̈ M‡o 30 wgwbU K‡i mgq jvM‡e e‡j Abygvb Kiv n‡q‡Q, Gi g‡a ̈ Aš—fz©3 i‡q‡Q wb‡`©kbv ch©v‡jvPbv, we` ̈gvb Z_ ̈fvÛvi 

AbymÜvb, ca‡qvRbxq Z_ ̈ÑDcvË msMan I i¶Yv‡e¶Y, Ges msM„nxZ Z_ ̈ m¤ú~Y© Kiv I ch©v‡jvPbvi Rb ̈ e ̈wqZ mgq; hw` †cavfvBWviiv Zv‡`i 

Pjgvb K¬v‡q›U/AskManYKvix Bb‡UK ev d‡jvAv‡ci Ask wn‡m‡e GB Z‡_ ̈i A‡bKLvwb BwZg‡a ̈B msMan K‡i _v‡K Zvn‡j Zvi Dci wfwË 

K‡i, mgq Kg jvM‡e| GB AvbygvwbK  ̧i“fvi m¤ú‡K© A_ev Z_ ̈ msMan m¤úwK©Z Ab ̈ †h †Kv‡bv wel‡q GB wVKvbvq gZvgZ cvVvb: SAMHSA 

Reports Clearance Officer, Room 7-1044, 1 Choke Cherry Road, Rockville, MD 20857. eZ©gv‡b ˆea †Kv‡bv OMB K‡›U«vj 

b¤¦i ca`k©b bv Ki‡j †Kv‡bv G‡RwÝ cwiPvjbv ev c„ô‡cvlKZv bvI Ki‡Z cv‡i, Ges †Kv‡bv e ̈w3 Z_ ̈ msMa‡ni Aby‡iv‡a mvov †`qvi Rb ̈ eva ̈

bq| GB ca‡R‡±i Rb ̈ K‡›U«vj b¤¦i n‡”Q 0930-0208. 
CSAT_GPRA_Client_Outcome_Instrument 1 v5.1

A. †iKW© e ̈e ̄’vcbv

K¬v‡q›U ID |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|

K¬v‡q‡›Ui aib:

wPwKrmvaxb K¬v‡q›U

wbivgqiZ K¬v‡q›U

K›U«v±/Ma ̈v›U ID |____|____|____|____|____|____|____|____|____|____|

mv¶vrKv‡ii aib [ïaygvÎ GKwU ai‡b †Mvj`vM w`b|]

Bb‡UK [mv¶vrKv‡ii Zvwi‡L P‡j hvb|]

6 gv‡mi d‡jvAvc → → → Avcwb wK †Kv‡bv d‡jvAvc mv¶vrKvi cwiPvjbv K‡i‡Qb? nu ̈v bv

[hw` bv nq, mivmwi †mKkb IÑ†Z P‡j hvb|]

3 gv‡mi d‡jvAvc [ïaygvÎ wK‡kviÑwK‡kvix‡`i †cvU©‡dvwjI] →

Avcwb wK †Kv‡bv d‡jvAvc mv¶vrKvi cwiPvjbv K‡i‡Qb? nu ̈v bv

[hw` bv nq, mivmwi †mKkb IÑ†Z P‡j hvb|]

wWmPvR© → → → Avcwb wK †Kv‡bv wWmPvR© mv¶vrKvi cwiPvjbv K‡i‡Qb? nu ̈v bv

[hw` bv nq, mivmwi †mKkb JÑ†Z P‡j hvb|]

mv¶vrKv‡ii ZvwiL |____|____| / |____|____| / |____|____|____|____|

 gvm w`b eQi

[d‡jvAvc Ges wWmPvR© mv¶vrKvi: †mKkb BÑ†Z P‡j hvb|]

1. Avcbvi K¬v‡q›U‡K wK hyMcrfv‡e gvbwmK  ̄^v ̄’ ̈ Ges gv`K`ae ̈ e ̈enviRwbZ e ̈vwa‡Z †fvMvi Rb ̈ Avcbvi

Kg©m~wP‡Z Aš—f©z3 Kiv n‡q‡Q?

nu ̈v

bv [1a.ev` w`‡q GwM‡q hvb]

1a. [hw` nu ̈v nq] K¬v‡q›U wK gvbwmK  ̄^v ̄’ ̈ Ges gv`K`ae ̈ e ̈enviRwbZ e ̈vwa‡Z GKmv‡_ †fvMvi welqwU 

aiv c‡o‡Q? 

nu ̈v

bv

[SBIRT Pj‡Q| Ab ̈ mevB †mKkb A ÒcwiKwíZ cwi‡levmg~nÓ†Z P‡j hvb|]
CSAT_GPRA_Client_Outcome_Instrument 2 v5.1

GB †mKkbwU ïaygvÎ SBIRT gÄzwimg~‡ni Rb ̈ [AvB‡Ug 2, 2a, I 3 - ïaygvÎ Bb‡UK/†emjvBbÑG D‡j­L Kiv n‡q‡Q]|

2. Avcbvi SBIRT-Gi Rb ̈ K¬v‡q›U †Kgb w ̄Œb K‡i‡Qb?

†b‡MwUf

c‡RwUf

2a. Zvi w ̄Œwbs † ̄‹vi KZ wQj? AUDIT = |____|____|

CAGE = |____|____|

DAST = |____|____|

DAST-10 = |____|____|

NIAAA MvBW = |____|____|

ASSIST/A ̈vj‡Kvnj mve‡ ̄‹vi = |____|____|

Ab ̈vb ̈ (D‡j­L Ki“b) = |____|____|

______________________________________

______________________________________

______________________________________

3. wZwb wK SBIRT Kg©m~wP‡Z Zvi AskManY Ae ̈vnZ ivL‡Z B”QzK wQ‡jb?

nu ̈v 

bv
CSAT_GPRA_Client_Outcome_Instrument 3 v5.1

A. †iKW© e ̈e ̄’vcbv Ñ cwiKwíZ cwi‡levmg~n [ïaygvÎ Bb‡UK/†emjvB‡b K¬v‡q›U m¤ú‡K© Kg©m~wPi Kg©x‡`i Øviv 

wi‡cvU©K...Z]

K¬v‡q‡›Ui wPwKrmv/Av‡ivM ̈jv‡fi mg‡q Avcwb K¬v‡q›U‡K 

†h me cwi‡lev ̧‡jv †`qvi cwiKíbv Ki‡Qb †m ̧‡jv 

wPwýZ Ki“b| [cawZwUi Rb ̈ nu ̈v n‡j Ônu ̈vÕ †Z A_ev bv n‡j 

ÔbvÕ †Z †Mvj`vM w`b|]

wPwKrmvi aib nu ̈v bv

[Kgc‡¶ GKwU aib wbe©vPb Ki“b|]

1. †Km e ̈e ̄’vcbv nu ̈v bv

2. w`evKvjxb wPwKrmv nu ̈v bv

3. fwZ© nIqv †ivMx/nvmcvZvj (gv`Kvkw3 wbivgq

e ̈ZxZ) nu ̈v bv

4. ewnwe©fvMxq †ivMx nu ̈v bv

5. AvDUwiP nu ̈v bv

6. wbweo ewnwe©fvMxq †ivMx nu ̈v bv

7. †g_v‡Wvb nu ̈v bv

8. AvevwmK/cybe©vmb nu ̈v bv

9. gv`Kvkw3 wbivgq (ïaygvÎ GKwU wbe©vPb Ki“b)

A. nvmcvZv‡j fwZ© nIqv †ivMx nu ̈v bv

B. wd« ÷ ̈vwÛs AvevwmK nu ̈v bv

C. ewnwe©fvMxq †ivMx‡`i gv`Kvkw3 wbivgq nu ̈v bv

10. cieZ©x cwiPh©v nu ̈v bv

11. wbivg‡q mnvqZv nu ̈v bv

12. Ab ̈vb ̈ (D‡j­L Ki“b) ___________________ nu ̈v bv

[Kgc‡¶ GKwU cwi‡lev wbe©vPb Ki“b|]

wPwKrmv †mev nu ̈v bv

[SBIRT gÄzwi: 1 †_‡K 4 Gi g‡a ̈ GKwU wPwKrmv 

†mevq Avcbv‡K Aek ̈B Ônu ̈vÕ †Z †Mvj`vM w`‡Z 

n‡e|]

1. w ̄Œwbs nu ̈v bv

2. msw¶ß n ̄—‡¶c nu ̈v bv

3. msw¶ß wPwKrmv nu ̈v bv

4. wPwKrmvi Rb ̈ †idvi Kiv nu ̈v bv

5. g~j ̈vqb nu ̈v bv

6. wPwKrmv/wbivg‡qi cwiKíbv nu ̈v bv

7. e ̈w3MZ civgk© †mev nu ̈v bv

8. `jMZ civgk© †mev nu ̈v bv

9. cvwievwiK/ˆeevwnK civgk© nu ̈v bv

10. hyMcr wPwKrmv/

wbivgq †mev nu ̈v bv

11. IlyawfwËK n ̄—‡¶c nu ̈v bv

12. HIV/GBWm m¤úwK©Z civgk© nu ̈v bv

13. Ab ̈vb ̈ wPwKrmv †mev

(D‡j­L Ki“b) ________________________ nu ̈v bv

†Km e ̈e ̄’vcbv cwi‡lev nu ̈v bv

1. cvwievwiK cwi‡lev (we‡q msμvš— wk¶v,

wcZ...Z¡/gvZ...Z¡, wkï Dbœqb cwi‡lev mn) nu ̈v bv

2. wkï cwiPh©v nu ̈v bv

3. Kg©ms ̄’vb msμvš— †mev

A. cavKÑKg©ms ̄’vb nu ̈v bv

B. Kg©ms ̄’vb msμvš— †KvwPs nu ̈v bv

4. e ̈w3MZ cwi‡levi mgš^q nu ̈v bv

5. cwienb nu ̈v bv

6. HIV/GBWm welqK cwi‡lev nu ̈v bv

7. mnvqZvg~jK μvwš—Kvjxb gv`KÑgy3 Avevmb †mev nu ̈v bv

8. Ab ̈vb ̈ †Km e ̈e ̄’vcbv cwi‡lev

(D‡j­L Ki“b) _______________________ nu ̈v bv

wPwKrmv †mev nu ̈v bv

1. wPwKrmv cwiPh©v nu ̈v bv

2. A ̈vj‡Kvnj/gv`K cix¶v nu ̈v bv

3. HIV/GBWm wPwKrmv mnvqZv I cix¶v nu ̈v bv

4. Ab ̈vb ̈ wPwKrmv †mev

(D‡j­L Ki“b) _______________________ nu ̈v bv

cwiPh©v cieZ©x †mev nu ̈v bv

1. Ae ̈vnZ cwiPh©v nu ̈v bv

2. cybivq wjß nIqv cawZ‡iva nu ̈v bv

3. wbivg‡qi †KvwPs nu ̈v bv

4. AvZ¥-mvnvh ̈ I mnvqZv `j nu ̈v bv

5. Ava ̈vwZ¥K mnvqZv nu ̈v bv

6. Ab ̈vb ̈ cwiPh©v cieZ©x †mev

(D‡j­L Ki“b) _______________________ nu ̈v bv

wk¶v cwi‡lev nu ̈v bv

1. gv`‡Ki Ace ̈envi m¤úwK©Z wk¶v nu ̈v bv

2. HIV/GBWm m¤úwK©Z wk¶v nu ̈v bv

3. Ab ̈vb ̈ wk¶v cwi‡lev

(D‡j­L Ki“b) _______________________ nu ̈v bv

m1⁄2xiÑØvivÑm1⁄2xi wbivgq mnvqZv cwi‡lev nu ̈v bv

1. m1⁄2x‡`i †KvwPs ev civgk© nu ̈v bv

2. evm ̄’vb mnvqZv nu ̈v bv

3. A ̈vj‡KvnjÑ I gv`KÑgy3 mvgvwRK Kvh©μg nu ̈v bv

4. Z_ ̈ I mycvwik nu ̈v bv

5. m1⁄2xiÑØvivÑm1⁄2xi Ab ̈vb ̈ wbivgq mnvqZv †mev

(D‡j­L Ki“b) _______________________ nu ̈v bv
CSAT_GPRA_Client_Outcome_Instrument 4 v5.1

A. †iKW© e ̈e ̄’vcbv Ñ RbmsL ̈vZvwË¡K [ïaygvÎ Bb‡UK/†emjvB‡b wRÁvmv Kivi Rb ̈]

1. Avcwb †Kvb wj‡1⁄2i?

cyi“l

gwnjv

U«vÝ‡RÛvi

Ab ̈vb ̈ (D‡j­L Ki“b) __________________________________

DËi w`‡Z Abxnv

2. Avcwb wK wn ̄úvwbK ev j ̈vwU‡bv?

nu ̈v

bv

DËi w`‡Z Abxnv

[hw` nu ̈v nq] Avcwb wb‡R‡K †Kvb RvwZMZ `‡ji Aš—fz3 e‡j we‡ePbv K‡ib? AbyMan K‡i wb‡Pi cawZwUi Rb ̈ 

nu ̈v ev bv DËi w`b| Avcwb GKwUi †ewk DË‡i nu ̈v ej‡Z cv‡ib|

nu ̈v bv DËi w`‡Z Abxnv

ga ̈ Av‡gwiKvb nu ̈v bv DËi w`‡Z Abxnv

wKDevb nu ̈v bv DËi w`‡Z Abxnv

WwgwbKvb nu ̈v bv DËi w`‡Z Abxnv

†gw·Kvb nu ̈v bv DËi w`‡Z Abxnv

cy‡q‡Z©vwiKvb nu ̈v bv DËi w`‡Z Abxnv

`w¶Y Av‡gwiKvb nu ̈v bv DËi w`‡Z Abxnv

Ab ̈vb ̈ nu ̈v bv DËi w`‡Z Abxnv [hw` nu ̈v nq, wb‡P mywbw`©ófv‡e D‡j­L Ki“b|]

(D‡j­L Ki“b) _________________________________ 

3. Avcwb †Kvb RvwZi? AbyMan K‡i wb‡Pi cawZwUi Rb ̈ nu ̈v ev bv DËi w`b| Avcwb GKwUi †ewk DË‡i nu ̈v ej‡Z

cv‡ib|

nu ̈v bv DËi w`‡Z Abxnv

K...òv1⁄2 ev Avwd«Kvb Av‡gwiKvb nu ̈v bv DËi w`‡Z Abxnv

Gkxq nu ̈v bv DËi w`‡Z Abxnv

nvIqvB ev Ab ̈ cakvš— gnvmvMixq Øx‡ci Awaevmx nu ̈v bv DËi w`‡Z Abxnv

Avjv ̄‹vi Avw`evmx nu ̈v bv DËi w`‡Z Abxnv

†k¦Zv1⁄2 nu ̈v bv DËi w`‡Z Abxnv

Av‡gwiKvb BwÛqvb nu ̈v bv DËi w`‡Z Abxnv

4. Avcbvi Rb¥w`b K‡e?*

|____|____| / |____|____| / [*wm‡÷g ïaygvÎ gvm I eQi msi¶Y Ki‡e|

gvm w`b †MvcbxqZv i¶vi Rb ̈ w`‡bi Z_ ̈ msi¶Y Kiv n‡e bv|]

|____|____|____|____|

eQi

DËi w`‡Z Abxnv
CSAT_GPRA_Client_Outcome_Instrument 5 v5.1

mvgwiK cwievi I wb‡qvwRZKiY

5. Avcwb wK KL‡bv mk ̄¿ evwnbx, wiRvf©, ev b ̈vkbvj MvW© evwnbx‡Z KvR K‡i‡Qb? [hw` K‡i _v‡Kb] mk ̄¿

evwnbx, wiRvf©, ev b ̈vkbvj MvW© evwnbxi †Kvb As‡k KvR K‡i‡Qb?

bv

nu ̈v, mk ̄¿ evwnbx‡Z

nu ̈v, wiRvf© evwnbx‡Z

nu ̈v, b ̈vkbvj MvW© evwnbx‡Z

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, ev Rvwb bv nq, Zvn‡j mivmwi cakœ A6 G P‡j hvb|]

5a. Avcwb wK eZ©gv‡b mk ̄¿ evwnbx, wiRvf©, ev b ̈vkbvj MvW© evwnbx‡Z mwμqfv‡e `vwqZ¡ cvjb K‡i‡Qb? 

[hw` K‡i _v‡Kb] †Kvb †¶‡Î, mk ̄¿ evwnbx, wiRvf©, bvwK b ̈vkbvj MvW© evwnbx? 

bv, mk ̄¿ evwnbx, wiRvf© ev b ̈vkbvj MvW© evwnbx †_‡K wew”Qbœ ev Aemicavß

nu ̈v, mk ̄¿ evwnbx‡Z

nu ̈v, wiRvf© evwnbx‡Z

nu ̈v, b ̈vkbvj MvW© evwnbx‡Z

DËi w`‡Z Abxnv

Rvwb bv

5b. Avcbv‡K wK KL‡bv hy×‡¶‡Î wb‡qvwRZ Kiv n‡qwQj? [ca‡hvR ̈ me ̧‡jv‡Z wUKwPý w`b|]

KL‡bvB wb‡qvwRZ Kiv nqwb

BivK ev AvdMvwb ̄—vb (†hgb, OEF/OIF/OND)

cvim ̈ DcmvMi (Acv‡ikb †WRvU© wkì/†WRvU© ÷g©)

wf‡qZbvg/`w¶Yc~e© Gwkqv

†Kvwiqv

wØZxq wek¦hy×

Dc‡i D‡j­L Kiv nqwb Ggb GKwU hy×‡¶‡Î wb‡qvwRZ Kiv n‡qwQj (†hgb, emwbqv/†mvgvwjqv)

DËi w`‡Z Abxnv

Rvwb bv

[SBIRT MavnK: †h me K¬v‡q›U †b‡MwUf wn‡m‡e w ̄Œwbs n‡q‡Qb, Zv‡`i Rb ̈ AvB‡Ug A6, A6a †_‡K A6d ch©š— mivmwi 

ev` w`‡q GwM‡q hvb]
CSAT_GPRA_Client_Outcome_Instrument 6 v5.1

6. Avcbvi cwiev‡ii †KD ev Avcbvi Nwbô †KD wK mk ̄¿ evwnbx, wiRvf© ev b ̈vkbvj MvW© evwnbx‡Z mwμqfv‡e

Kg©iZ Av‡Qb, A_ev mk ̄¿ evwnbx, wiRvf© ev b ̈vkbvj MvW© evwnbx †_‡K wew”Qbœ ev Aemicavß n‡q‡Qb?

bv

nu ̈v, †KejgvÎ GKRb

nu ̈v, GKvwaK

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, ev Rvwb bv nq, Zvn‡j mivmwi †mKkb B †Z P‡j hvb|]

[hw` nu ̈v nq, 6 Rb ch©š— e ̈w3i Rb ̈ DËi w`b] Avcbvi mv‡_ †mB e ̈w3i (mvwf©m †g¤¦vi) m¤úK© Kx? [Kjv‡gi 

wk‡ivbv‡g m¤úK© wjLyb]

1 = gv 2 = evev

3 = fvB 4 = †evb

5 =  ̄^vgx/ ̄¿x 6 = cvU©bvi

7 = mš—vb 8 = Ab ̈vb ̈ (D‡j­L Ki“b) ___________________

mvwf©m †g¤¦vi wK wb‡Pi 

†Kv‡bvwUi m¤§zLxb 

n‡qwQ‡jb? [ca‡hvR ̈ 

me ̧‡jvi Rb ̈ h_vh_ 

DË‡ii Kjv‡g wUKwPý w`b]

_________

(m¤úK©) 

1. 

_________

(m¤úK©) 

2. 

_________

(m¤úK©) 

3. 

_________

(m¤úK©) 

4. 

_________

(m¤úK©) 

5. 

_________

(m¤úK©) 

6. 

6a. mk ̄¿ Acv‡ik‡b 

mnvqZv Kivi Rb ̈ 

wb‡qvwRZ Kiv n‡qwQj 

wK (†hgb, Biv‡K ev 

AvdMvwb ̄—v‡b)? 

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

6b. mk ̄¿ Acv‡ik‡b 

kvixwiKfv‡e AvnZ 

n‡qwQ‡jb? 

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

6c. hy‡×i Pv‡ci j¶Y ̧‡jv 

†`Lv w`‡qwQj/ 

wb‡qvwRZ nIqvi ci 

gvwb‡q wb‡Z mgm ̈v 

n‡qwQj, hvi g‡a ̈ 

i‡q‡Q PTSD, welbœZv, 

ev AvZ¥nZ ̈vi wPš—v?

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

6d. gviv wM‡q‡Qb ev wbnZ 

n‡q‡Qb? 

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv

 nu ̈v

 bv

 DËi w`‡Z

Abxnv

 Rvwb bv
CSAT_GPRA_Client_Outcome_Instrument 7 v5.1

B. gv`K I A ̈vj‡Kvnj e ̈envi 

 w`‡bi DËi w`‡Z Rvwb bv

 msL ̈v Abxnv (RF) (DK)

1. MZ 30 w`‡b, Avcwb wb‡P Dwj­wLZ ̧‡jv KZ w`b e ̈envi K‡i‡Qb:

a. †h †Kv‡bv A ̈vj‡Kvnj [hw` k~b ̈ nq, Zvn‡j mivmwi AvB‡Ug B1cÑ†Z P‡j 

hvb|] |____|____|

b1. †bkv Kivi Rb ̈ A ̈vj‡Kvnj (GK ˆeV‡K 5+ wW«sK) |____|____|

b2. †bkvi Rb ̈ A ̈vj‡Kvnj (GK ˆeV‡K 4wU ev Zvi Kg wW«sK I †bkv †eva Kiv) |____|____|

c. A‰ea gv`K [hw` B1a A_ev B1c = 0, DËi w`‡Z Abxnv (RF), ev Rvwb bv 

(DK) nq Zvn‡j mivmwi AvB‡Ug B2Ñ†Z P‡j hvb|] |____|____|

d. A ̈vj‡Kvnj Ges gv`K DfqB (GKB w`‡b) |____|____|

ca‡qvM c‡_i aib:

1. gy‡L 2. bv‡K 3. a~gcvb 4. wkivc‡_ bq Ggb Bb‡RKkb 5. wkiv c‡_

*mvaviY ca‡qvM c_ D‡j­L Ki“b| GKwUi †ewk ca‡qvM c‡_i Rb ̈, me‡P‡q  ̧i“ZiwU

D‡j­L Ki“b| ca‡qvM c_ ̧‡jv ZvwjKvfz3 Kiv n‡q‡Q me‡P‡q Kg  ̧i“Zi (1) †_‡K 

me‡P‡q †ewk  ̧i“Zi (5) wn‡m‡e|

2. MZ 30 w`‡b, Avcwb wb‡P Dwj­wLZ ̧‡jv KZ w`b e ̈envi K‡i‡Qb:

[B2a †_‡K B2i ch©š— †Kv‡bv AvB‡U‡gi gvb 0ÑGi †P‡q eo n‡j, B1cÑGi gvb 

Aek ̈B 0ÑGi †P‡q eo n‡e|]

w`‡bi ca‡qvM 

 msL ̈v RFDK c_* RF DK

a. †Kv‡KBb/μ ̈vK |____|____| |____|

b. gvwiRyqvbv/nvwkk (cU, R‡q›U, e­v›U, μwbK, DBW, †gwi, †Rb) |____|____| |____|

c. Avwdg:

1. †n‡ivBb ( ̄§ ̈vK, GBP, RvsK,  ̄‹ ̈vM) |____|____| |____|

2. giwdb |____|____| |____|

3. wWjyqvwWW |____|____| |____|

4. †W‡gij |____|____| |____|

5. cvi‡Kv‡mU |____|____| |____|

6. Wvifb |____|____| |____|

7. †Kv‡WBb |____|____| |____|

8. UvB‡jbj 2, 3, 4 |____|____| |____|

9. Aw·KbwUb/Aw·‡KvWb |____|____| |____| ‘ 

d. †camwμckbwenxb †g_v‡Wvb |____|____| |____|

e. `„wóåg m„wóKvix/Db¥v`RbK, PCP (A ̈v‡Äj Wv÷, I‡Rvb, Iq ̈vK, i‡KU

dz‡qj) MDMA (G·U ̈vwm, XTC, G·, GWvg), LSD (GwmW, eygvm©,

B‡q‡jv mvbkvBb), gvki“g ev †gmKvwjb |____|____| |____|

f. †g_vg‡dUvwgb ev Ab ̈ A ̈vwçUvwgb (†g_, Avcvi, w ̄úW, AvBm, PK,

wμ÷vj, M­vm, dvqvi, μ ̈vsK) |____|____| |____|
CSAT_GPRA_Client_Outcome_Instrument 8 v5.1

B. gv`K I A ̈vj‡Kvnj e ̈envi (μgkt)

ca‡qvM c‡_i aib:

1. gy‡L 2. bv‡K 3. a~gcvb 4. wkivc‡_ bq Ggb Bb‡RKkb 5. wkiv c‡_

*mvaviY ca‡qvM c_ D‡j­L Ki“b| GKwUi †ewk ca‡qvM c‡_i Rb ̈, me‡P‡q  ̧i“ZiwU

D‡j­L Ki“b| ca‡qvM c_ ̧‡jv ZvwjKvfz3 Kiv n‡q‡Q me‡P‡q Kg  ̧i“Zi (1) †_‡K 

me‡P‡q †ewk  ̧i“Zi (5) wn‡m‡e|

2. MZ 30 w`‡b, Avcwb wb‡P Dwj­wLZ ̧‡jv KZ w`b e ̈envi K‡i‡Qb:

[B2a †_‡K B2i ch©š— †Kv‡bv AvB‡U‡gi gvb 0ÑGi †P‡q eo n‡j, 

B1cÑGi gvb Aek ̈B 0ÑGi †P‡q eo n‡e|] w`‡bi ca‡qvM 

 msL ̈v RFDK c_* RF DK

g. 1. †eb‡RvWvqv‡Rwcb: Wvqv‡Rcvg (f ̈vwjqvg); Avjcav‡Rvjvg (R ̈vbv·); 

U«vqv‡Rvjvg (n ̈vjwmqb); Ges GmUv‡mvjvg (†cavmg I 

†ivwncbjÑGQvovI i“wdm, †ivP, I †Kvc bv‡gI cwiwPZ) |____|____| |____|

2. evwe©Pz‡iU: †g‡dvevwe©Uvj (†gevKvU); Ges †c‡›Uvevwe©Uvj †mvwWqvg

(†bgweDUvj) |____|____| |____|

3. †camwμckbÑwenxb GHB (wMafvm& ewWwj nvg©; wjKzBW G·U ̈vwm; I

RwR©qv †nvg eq bv‡g cwiwPZ) |____|____| |____|

4. †KUvwgb († ̄úkvj K ev wfUvwgb K bv‡g cwiwPZ) |____|____| |____|

5. Ab ̈vb ̈ cakvwš—`vqK, D‡ËRbv cakgbKvix, wb`avKviK ev m‡¤§vnbx gv`K |____|____| |____|

h. wbtk¦v‡mi mv‡_ M„nxZ (ccvi, mœ ̈vcvi, ivk, ûB‡cU) |____|____| |____|

i. Ab ̈vb ̈ A‰ea gv`K (D‡j­L Ki“b) ___________________________ |____|____| |____|

3. MZ 30 w`‡b, Avcwb wK Bb‡RKk‡bi gva ̈‡g gv`K wb‡q‡Qb? [hw` B2a †_‡K B2i ch©š— Man‡Yi c_ = 4 ev 5 nq, Zvn‡j, 

Aek ̈B B3 = nu ̈v n‡e|]

nu ̈v

bv

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, A_ev Rvwb bv nq, Zvn‡j mivmwi †mKkb CÑ†Z P‡j hvb|]

4. MZ 30 w`‡b, Avcwb KZ Nb Nb Ab ̈ Kv‡iv e ̈envi Kiv wmwiÄ/muyB, KzKvi, Zzjv ev cvwb e ̈envi K‡i‡Qb?

me mgq

A‡a©‡Ki †ewk mgq

A‡a©K mgq

A‡a©‡Ki Kg mgq

KL‡bvB bq

DËi w`‡Z Abxnv

Rvwb bv
CSAT_GPRA_Client_Outcome_Instrument 9 v5.1

C. cwievi I emev‡mi Ae ̄’v

1. MZ 30 w`‡b, Avcwb †ewkifvM mgq †Kv_vq emevm K‡i‡Qb? [K¬v‡q›U‡`i‡K DË‡ii Ackb ̧‡jv c‡o †kvbv‡eb 

bv|]

Avkaq (wbivc` Avkaq [†md †n‡fb], μvwš—Kvjxb Avkaq †K›`a [U« ̈vbwRkbvj wjwfs †m›Uvi, wUGjwm], Kg Pvwn`vhy3  ̄’vcbv, 

wi‡mckb †m›Uvi, Ab ̈vb ̈ A ̄’vqx w`ev ev mvÜ ̈Kvjxb †K›`a)

iv ̄—v/AvDU‡Wvi (dzUcvZ, `iRvi mvg‡b, cvK©, miKvwi ev cwiZ ̈3 feb)

cawZôvb (nvmcvZvj, bvwm©s †nvg, †Rj/KvivMvi)

evmvq: [hw` evmvq nq, Zvn‡j h_vh_ Dcwefv‡M wUKwPý w`b:]

wbR ̄^/fvov A ̈vcvU©‡g›U, i“g, ev evwo

Ab ̈ Kv‡iv A ̈vcvU©‡g›U, i“g, ev evwo

W‡g©Uwi/K‡j‡Ri nj

nvdI‡q nvDm

AvevwmK wPwKrmv

Ab ̈vb ̈ ai‡bi AvevwmK (D‡j­L Ki“b) ___________________________________________________________ 

DËi w`‡Z Abxnv

Rvwb bv

2. MZ 30 w`‡b, Avcbvi A ̈vj‡Kvnj ev Ab ̈vb ̈ gv`K e ̈envi Kivi Kvi‡Y Avcbvi Rb ̈ wewfbœ welq ̧‡jv KZUv

cxov`vqK wQj? [hw` B1a A_ev B1c > 0 nq, Zvn‡j C2 = Òca‡hvR ̈ bqÓ n‡Z cv‡i bv|]

G‡Kev‡iB bq

wKQzUv

D‡j­L‡hvM ̈fv‡e

AZ ̈š—

ca‡hvR ̈ bq [ïaygvÎ B1a Ges B1c = 0 n‡j e ̈envi Ki“b|]

DËi w`‡Z Abxnv

Rvwb bv

3. MZ 30 w`‡b, Avcbvi A ̈vj‡Kvnj ev Ab ̈vb ̈ gv`K e ̈envi Kivi Kvi‡Y Avcbv‡K wK  ̧i“Z¡c~Y© KvRKg© Kwg‡q

†dj‡Z ev †Q‡o w`‡Z n‡q‡Q? [hw` B1a A_ev B1c > 0 nq, Zvn‡j C3 = Òca‡hvR ̈ bqÓ n‡Z cv‡i bv|]

G‡Kev‡iB bq

wKQzUv

D‡j­L‡hvM ̈fv‡e

AZ ̈š—

ca‡hvR ̈ bq [ïaygvÎ B1a Ges B1c = 0 n‡j e ̈envi Ki“b|]

DËi w`‡Z Abxnv

Rvwb bv
CSAT_GPRA_Client_Outcome_Instrument 10 v5.1

C. cwievi I emev‡mi Ae ̄’v (μgkt)

4. MZ 30 w`‡b, Avcbvi A ̈vj‡Kvnj ev Ab ̈vb ̈ gv`K e ̈envi Kivi Kvi‡Y Avcbvi wK Av‡eM m¤úwK©Z mgm ̈v

n‡q‡Q? [hw` B1a A_ev B1c > 0 nq, Zvn‡j C4 = Òca‡hvR ̈ bqÓ n‡Z cv‡i bv|]

G‡Kev‡iB bq

wKQzUv

D‡j­L‡hvM ̈fv‡e

AZ ̈š—

ca‡hvR ̈ bq [ïaygvÎ B1a Ges B1c = 0 n‡j e ̈envi Ki“b|]

DËi w`‡Z Abxnv

Rvwb bv

5. [cyi“l bv n‡j] Avcwb wK eZ©gv‡b Mf©eZx?

nu ̈v

bv

DËi w`‡Z Abxnv

Rvwb bv

6. Avcbvi wK †Q‡j‡g‡q Av‡Q?

nu ̈v

bv

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, A_ev Rvwb bv nq, Zvn‡j mivmwi †mKkb DÑ†Z P‡j hvb|]

a. Avcbvi KqwU †Q‡j‡g‡q Av‡Q? [hw` C6 = nu ̈v nq, Zvn‡j C6a Gi gvb Aek ̈B 0ÑGi †P‡q eo n‡e|]

|____|____| DËi w`‡Z Abxnv Rvwb bv

b. Av`vj‡Zi †Kv‡bv wkï myi¶v Av‡`‡ki Kvi‡Y Avcbvi †Kv‡bv †Q‡j‡g‡q wK Ab ̈ Kv‡iv mv‡_ emevm

Ki‡Q?

nu ̈v

bv

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, A_ev Rvwb bv nq, Zvn‡j mivmwi AvB‡Ug C6d-†Z P‡j hvb|]

c. [hw` nu ̈v nq] Av`vj‡Zi wkï myi¶v Av‡`‡ki Kvi‡Y Avcbvi KqwU †Q‡j‡g‡q Ab ̈ Kv‡iv mv‡_ emevm

Ki‡Q? [C6cÑGi gvb C6aÑGi gv‡bi †P‡q eo n‡Z cvi‡e bv|]

|____|____| DËi w`‡Z Abxnv Rvwb bv

d. Avcbvi KqwU †Q‡j‡g‡qi Rb ̈ Avcwb wcZ...‡Z¡i/gvZ...‡Z¡i AwaKvi nvwi‡q‡Qb? [K¬v‡q‡›Ui 

wcZ...‡Z¡i/gvZ...‡Z¡i AwaKvi †K‡o †bIqv n‡q‡Q|] [AvB‡Ug C6dÑGi gvb C6aÑGi gv‡bi †P‡q eo n‡Z 

cvi‡e bv|]

|____|____| DËi w`‡Z Abxnv Rvwb bv
CSAT_GPRA_Client_Outcome_Instrument 11 v5.1

D. wk¶v, Kg©ms ̄’vb, I Avq

1. Avcwb wK eZ©gv‡b †Kv‡bv  ̄‹zj ev Kg©ms ̄’vb cawk¶Y Kg©m~wP‡Z fwZ© n‡q Av‡Qb? [hw` fwZ© _v‡Kb] GUv wK

c~Y©Kvjxb bvwK LÛKvjxb? [hw` K¬v‡q›U Kvivi“× _v‡Kb Zvn‡j D1ÑGi Rb ̈ †KvW Ki“b ÒfwZ© n‡q †bBÓ|]

fwZ© n‡q †bB

fwZ© n‡q Av‡Qb, c~Y©Kvjxb

fwZ© n‡q Av‡Qb, LÛKvjxb

Ab ̈vb ̈ (D‡j­L Ki“b) __________________________________

DËi w`‡Z Abxnv

Rvwb bv

2. Avcwb †Kv‡bv wWMax †c‡q _v‡Kb ev bv _v‡Kb, Avcwb m‡e©v”P †Kvb ch©v‡qi wk¶v m¤úbœ K‡i‡Qb?

KL‡bv  ̄‹z‡j cwowb

 1g †MaW

 2q †MaW

 3q †MaW

 4_© †MaW

 5g †MaW

 6ô †MaW

 7g †MaW

 8g †MaW

 9g †MaW

 10g †MaW

 11Zg †MaW

 12Zg †MaW/nvB  ̄‹zj wW‡c­vgv/mggvb

 K‡jR ev BDwbfvwm©wU/1g eQi m¤úbœ

 K‡jR ev BDwbfvwm©wU/2q eQi m¤úbœ/mswk­ó wWMax (AA, AS)

 K‡jR ev BDwbfvwm©wU/3q eQi m¤úbœ

 mœvZK wWMax (BA, BS) ev D”PZi

 nvB  ̄‹z‡ji c‡i e„wËg~jK/KvwiMwi Kg©m~wP‡Z AskManY wKš‘ †Kv‡bv e„wËg~jK/KvwiMwi wW‡c­vgv †bB

 nvB  ̄‹z‡ji c‡i e„wËg~jK/KvwiMwi wW‡c­vgv 

 DËi w`‡Z Abxnv 

 Rvwb bv

3. Avcwb wK eZ©gv‡b Kg©iZ? [MZ mßv‡ni †ewkifvM As‡ki Dci g‡bv‡hvM †`qvi gva ̈‡g cwi®‹vi Ki“b †h, 

K¬v‡q›U G‡Kev‡iB KvR K‡iwQ‡jb wKbv A_ev Zvi wbqwgZ PvKwi wQj wKbv hv †_‡K wZwb QzwU‡Z wQ‡jb|] [hw` 

K¬v‡q›U D1ÑGi DË‡i e‡jb ÒfwZ© n‡q Av‡Qb, c~Y©KvjxbÓ Ges D3ÑGi DË‡i e‡jb Òc~Y©Kvjxb PvKwiÓ, 

Zvn‡j GB welqwU e ̈vL ̈v Ki‡Z ejyb| hw` K¬v‡q›U Kvivi“× _v‡Kb Ges KvivMv‡ii evB‡i Zvi †Kv‡bv KvR bv 

_v‡K, Zvn‡j D3ÑGi Rb ̈ †KvW Ki“b Ò†eKvi, KvR LyuR‡Qb bvÓ|]

 c~Y©Kvjxb PvKwiiZ (cawZ mßv‡n 35+ N›Uv, A_ev KiwQ‡jb)

 LÛKvjxb PvKwiiZ

 †eKvi, KvR LyuR‡Qb

 †eKvi, cawZeÜx

 †eKvi, † ̄^”Qv‡mevg~jK KvR

 †eKvi, Aemicavß

 †eKvi, KvR LyuR‡Qb bv

 Ab ̈vb ̈ (D‡j­L Ki“b) ________________________________________

 DËi w`‡Z Abxnv

 Rvwb bv
CSAT_GPRA_Client_Outcome_Instrument _Client_Outc 12 v5.1

D. wk¶v, Kg©ms ̄’vb, I Avq (μgkt)

4. MZ 30 w`‡b Avcwb wb‡P Dwj­wLZ iƒ‡c cavq Kx cwigvY A_© †c‡q‡Qb (KiÑc~e© e ̈w3MZ Avq)...

[hw` D3 =ÒPvKwiiZÓ bv nq Ges D4aÑGi gvb k~‡b ̈i †P‡q eo nq, Zvn‡j wRÁvmv Ki“b| hw` D3 = Ò†eKvi, 

KvR LyuR‡QbÓ nq Ges D4b = 0 nq, Zvn‡j wRÁvmv Ki“b| hw` D3 = Ò†eKvi, AemicavßÓ nq Ges D4c = 0

nq, Zvn‡j wRÁvmv Ki“b| hw` D3 = Ò†eKvi, cawZeÜxÓ nq Ges D4d = 0 nq, Zvn‡j wRÁvmv Ki“b|]

RF DK

a. †eZb $ |__|__|__| , |__|__|__|

b. miKvwi mnvqZv $ |__|__|__| , |__|__|__|

c. Aemi fvZv $ |__|__|__| , |__|__|__|

d. cawZeÜxZ¡ $ |__|__|__| , |__|__|__|

e. A‰ea Avq $ |__|__|__| , |__|__|__|

f. cwievi Ges/A_ev eÜz $ |__|__|__| , |__|__|__|

g. Ab ̈vb ̈ (D‡j­L Ki“b) $ |__|__|__| , |__|__|__|

___________________

E. Aciva Ges Aciv‡ai wePv‡ii Ae ̄’v

1. MZ 30 w`‡b, Avcwb KZevi †Maßvi n‡q‡Qb?

|____|____| evi DËi w`‡Z Abxnv Rvwb bv

[hw` GKeviI †Maßvi bv nb, Zvn‡j mivmwi AvB‡Ug E3Ñ†Z P‡j hvb|]

2. MZ 30 w`‡b, Avcwb gv`KÑmswk­ó Kvi‡Y KZevi †Maßvi n‡q‡Qb? [E2ÑGi gvb E1ÑGi †P‡q eo n‡Z cvi‡e 

bv|]

|____|____| evi DËi w`‡Z Abxnv Rvwb bv

3. MZ 30 w`‡b, Avcwb KZ ivZ nvR‡Z/KvivMv‡i wQ‡jb? [hw` E3ÑGi gvb 15ÑGi †P‡q eo nq, Zvn‡j Aek ̈B 

C1 = cawZôvb (nvRZ/KvivMvi) n‡e| hw` C1 = cawZôvb (nvRZ/KvivMvi) nq, Zvn‡j E3ÑGi gvb Aek ̈B 15 Gi 

mgvb ev Zvi‡P‡q eo n‡e|]

|____|____| ivZ DËi w`‡Z Abxnv Rvwb bv

4. MZ 30 w`‡b, Avcwb KZevi Aciva K‡i‡Qb? [KZ w`b A‰ea gv`K ManY K‡i‡Qb Zv c„ôv 7ÑGi AvB‡Ug 

B1cÑ†Z †`Lyb| GLv‡b E4ÑGi DËi B1cÑGi msL ̈vi mgvb ev Zvi‡P‡q eo n‡e KviY A‰ea gv`K e ̈envi Kiv 

GKUv Aciva|]

|____|____|____| evi DËi w`‡Z Abxnv Rvwb bv

5. Avcwb wK eZ©gv‡b Awfhy3 nIqv, wePv‡ii m¤§zLxb nIqv, ev `Û cvIqvi Rb ̈ A‡c¶v Ki‡Qb?

nu ̈v

bv

DËi w`‡Z Abxnv

Rvwb bv

6. Avcwb wK eZ©gv‡b c ̈v‡iv‡j ev ca‡ek‡b Av‡Qb?

nu ̈v

bv

DËi w`‡Z Abxnv
CSAT_GPRA_Client_Outcome_Instrument 13 v5.1

Rvwb bv

F. gvbwmK I kvixwiK  ̄^v‡ ̄’ ̈i mgm ̈v Ges wPwKrmv/wbivgq

1. GB gyû‡Z© Avcbvi mvwe©K  ̄^v ̄’ ̈‡K Avcwb Kxfv‡e g~j ̈vqb Ki‡eb?

PgrKvi

Lye fv‡jv

fv‡jv

†gvUvgywU

Lvivc

DËi w`‡Z Abxnv

Rvwb bv

2. MZ 30 w`‡b, Avcwb wK wb‡P Dwj­wLZ ̧‡jv †c‡q‡Qb:

a. wb‡P Dwj­wLZ ̧‡jvi Rb ̈ nvmcvZv‡j

fwZ© †_‡K wPwKrmv:

nu ̈v

[hw` nu ̈v nq] me wgwj‡q †gvU KZ 

ivZ bv RF DK

i. kvixwiK Amy ̄’Zv ________ ivZ

ii. gvbwmK ev Av‡eMMZ mgm ̈v ________ ivZ

iii. A ̈vj‡Kvnj ev gv`‡Ki Ace ̈envi ________ ivZ

b. wb‡P Dwj­wLZ ̧‡jvi Rb ̈ ewnwe©fvM

†_‡K wPwKrmv:

nu ̈v

 [hw` nu ̈v nq] 

me wgwj‡q †gvU KZ 

ivZ bv RF DK

i. kvixwiK Amy ̄’Zv _________evi

ii. gvbwmK ev Av‡eMMZ mgm ̈v _________evi

iii. A ̈vj‡Kvnj ev gv`‡Ki Ace ̈envi _________evi

c. wb‡P Dwj­wLZ ̧‡jvi Rb ̈ Ri“wi wefv‡Mi

wPwKrmv:

nu ̈v

 [hw` nu ̈v nq] 

me wgwj‡q †gvU KZ 

ivZ bv RF DK

i. kvixwiK Amy ̄’Zv _________evi

ii. gvbwmK ev Av‡eMMZ mgm ̈v _________evi

iii. A ̈vj‡Kvnj ev gv`‡Ki Ace ̈envi _________evi
CSAT_GPRA_Client_Outcome_Instrument 14 v5.1

F. gvbwmK I kvixwiK  ̄^v‡ ̄’ ̈i mgm ̈v Ges wPwKrmv/wbivgq (μgkt)

3. MZ 30 w`‡b, Avcwb wK †hŠbK‡g© RwoZ n‡q‡Qb?

nu ̈v

bv → [mivmwi F4ÑG P‡j hvb|]

wRÁvmv Kivi Rb ̈ Aby‡gvw`Z bq → [mivmwi F4ÑG P‡j hvb|]

DËi w`‡Z Abxnv → [mivmwi F4ÑG P‡j hvb|]

Rvwb bv → [mivmwi F4ÑG P‡j hvb|]

[hw` nu ̈v nq] me wgwj‡q, KZ evi:

msmM©© RF DK

a. Avcwb wK †hŠb msmM© (†hvwbc‡_, gy‡L, ev cvqyc‡_) K‡i‡Qb? |____|____|____|

b. Avcwb wK Aiw¶Z †hŠb msmM© K‡i‡Qb? [F3bÑGi gvb F3aÑGi 

gv‡bi †P‡q eo n‡Z cvi‡e bv|] [hw` k~b ̈ nq, Zvn‡j 

F4ÑG P‡j hvb|] |____|____|____|

c. Ggb GKRb e ̈w3i mv‡_ Aiw¶Z †hŠb msmM© K‡i‡Qb hvi eZ©gvb ev

AZx‡Zi Ae ̄’v n‡”Q: [F3c1 †_‡K F3c3 ch©š— †KvbwUi gvb 

F3bÑGi gv‡bi †P‡q eo n‡Z cvi‡e bv|]

1. HIV c‡RwUf ev GBWm Av‡Q |____|____|____|

2. Bb‡RKk‡bi gva ̈‡g gv`K e ̈enviKvix |____|____|____|

3. wKQz wKQz gv`K ManY K‡i †bkv K‡ib |____|____|____|

4. Avcwb Kx KL‡bv HIVÑGi cix¶v Kwi‡q‡Qb?

nu ̈v ............................[F4aÑ†Z P‡j hvb|]

bv .............................[mivmwi F5ÑG P‡j hvb|]

DËi w`‡Z Abxnv .........[mivmwi F5ÑG P‡j hvb|]

Rvwb bv......................[mivmwi F5ÑG P‡j hvb|]

4a. Avcwb wK Avcbvi HIV cix¶vi djvdj Rv‡bb? 

nu ̈v

bv
CSAT_GPRA_Client_Outcome_Instrument 15 v5.1

F. gvbwmK I kvixwiK  ̄^v‡ ̄’ ̈i mgm ̈v Ges wPwKrmv/wbivgq (μgkt)

5. MZ 30 w`‡b, Avcbvi A ̈vj‡Kvnj ev gv`K e ̈envi bv Kivi Kvi‡Y, Avcwb KZ w`b:

w`b RF DK

a. gvivZ¥K welbœZvq fz‡M‡Qb |____|____|

b. gvivZ¥K `ywðš—v ev D‡ËRbvq fz‡M‡Qb |____|____|

c. `„wóweå‡g fz‡M‡Qb |____|____|

d. eyS‡Z, g‡bv‡hvM w`‡Z, ev g‡b ivL‡Z mgm ̈vq c‡o‡Qb |____|____|

e. wnsma AvPiY wbqš¿Y Ki‡Z Amyweavq c‡o‡Qb |____|____|

f. AvZ¥nZ ̈vi †Póv K‡i‡Qb |____|____|

g. gvbwmK/Av‡eMMZ mgm ̈vi Kvi‡Y Ily‡ai †camwμckb †c‡q‡Qb |____|____|

[hw` cakœ 5ÑGi me ̧‡jv AvB‡U‡gi DË‡i K¬v‡q›U k~b ̈ w`b, RF ev DK wi‡cvU© K‡ib, Zvn‡j mivmwi AvB‡Ug 

F7 G P‡j hvb|]

6. MZ 30 w`‡b GB me gvbwmK ev Av‡eMMZ mgm ̈vi Kvi‡Y Avcwb KZUv Amyweavq c‡owQ‡jb?

G‡Kev‡iB bq

wKQzUv

†gvUvgywU

D‡j­L‡hvM ̈fv‡e

AZ ̈š—

DËi w`‡Z Abxnv

Rvwb bv

mwnsmZv I gvbwmK AvNvZ

7. Avcwb Kx KL‡bv †Kv‡bv cwi‡e‡k mwnsmZv ev gvbwmK AvNv‡Zi m¤§zLxb n‡qwQ‡jb (Gi g‡a ̈ i‡q‡Q

KwgDwbwU‡Z ev  ̄‹z‡j mwnsmZv; cvwievwiK mwnsmZv; cwiev‡ii †fZ‡i ev evB‡i kvixwiK, gvbwmK, ev †hŠb

Ace ̈envi/AvμgY; cavK...wZK `y‡h©vM; mš¿vmev`; Ae‡njv; ev gvbwmK AvNvZRwbZ `ytL?)

nu ̈v

bv [mivmwi AvB‡Ug F8 G P‡j hvb|]

DËi w`‡Z Abxnv

Rvwb bv

[hw` bv, DËi w`‡Z Abxnv, ev Rvwb bv nq, Zvn‡j AvB‡Ug mivmwi F8 G P‡j hvb|]
CSAT_GPRA_Client_Outcome_Instrument 16 v5.1

F. gvbwmK I kvixwiK  ̄^v‡ ̄’ ̈i mgm ̈v Ges wPwKrmv/wbivgq (μgkt)

GB AwfÁZv ̧‡jvi †Kv‡bvwU Kx GZUv fxwZKi, fqvbK, ev wech©qKi wQj †h, AZx‡Z Ges/A_ev eZ©gv‡b, 

Avcwb:

7a. GwU m¤ú‡K© `yt ̄^cœ †`‡LwQ‡jb ev Avcwb hLb Pvbwb ZL‡bv GwU m¤ú‡K© wPš—v K‡iwQ‡jb? 

nu ̈v

bv

DËi w`‡Z Abxnv

Rvwb bv

7b. GwU m¤ú‡K© wPš—v bv Kivi Rb ̈ K‡Vvifv‡e †Póv K‡iwQ‡jb A_ev Avcbv‡K Gi K_v g‡b Kwi‡q †`q 

GB iKg cwiw ̄’wZ Gov‡bvi Rb ̈ caej †Póv K‡iwQ‡jb? 

nu ̈v

bv

DËi w`‡Z Abxnv

Rvwb bv

7c. μgvMZfv‡e mZK© wQ‡jb, ch©‡e¶Y KiwQ‡jb, ev mn‡RB Pg‡K DVwQ‡jb? 

nu ̈v

bv

DËi w`‡Z Abxnv

Rvwb bv

7d. Ab ̈ †jvKRb, Kg©KvÛ, ev Avcbvi Pvicvk †_‡K wew”Qbœ ev Abyf‚wZk~b ̈ †eva KiwQ‡jb? 

nu ̈v

bv

DËi w`‡Z Abxnv

Rvwb bv

8. MZ 30 w`‡b, Avcwb KZ Nb Nb AvNvZ, jvw_, ev Po †L‡q‡Qb, A_ev Ab ̈ †Kv‡bvfv‡e kvixwiKfv‡e AvNvZ

†c‡q‡Qb?

KL‡bvB bq

K‡qK evi

K‡qK ev‡ii †P‡q †ewk

DËi w`‡Z Abxnv

Rvwb bv
CSAT_GPRA_Client_Outcome_Instrument 17 v5.1

G. mvgvwRK †hvM‡hvM

1. MZ 30 w`‡b, Avcwb wK wbivg‡qi Rb ̈ Ggb †Kv‡bv † ̄^”Qv‡mex  ̄^q¤¢i †Mvôx‡Z AskManY K‡i‡Qb hv †Kv‡bv

ag©xq ev wek¦vmÑwfwËK msMV‡bi mv‡_ m¤ú„3 wQj bv? Ab ̈ K_vq ejv hvq, Avcwb wK †Kv‡bv AÑ†ckv`vi,

m1⁄2xÑcwiPvwjZ msMV‡b AskManY K‡i‡Qb hv Ggb gvbyl‡`i‡K mvnvh ̈ Kivi Rb ̈ wb‡ew`Z hv‡`i gv`Kvmw3

mswk­ó mgm ̈v Av‡Q, †hgb: A ̈vj‡KvnwjKm& A ̈v‡bvwbgvm, bvi‡KvwUKm& A ̈v‡bvwbgvm, A·‡dvW© nvDm,

†mKzjvi AM©vbvB‡Rkb di meiv‡qwU, ev DB‡gb di meiv‡qwU, BZ ̈vw`?

nu ̈v [hw` nu ̈v nq] D‡j­L Ki“b KZ evi |____|____| DËi w`‡Z Abxnv Rvwb bv

bv

DËi w`‡Z Abxnv

Rvwb bv

2. MZ 30 w`‡b, Avcwb wK †Kv‡bv ag©xq/wek¦vm wfwËK wbivgq  ̄^q¤¢i †Mvôx‡Z AskManY K‡i‡Qb?

nu ̈v [hw` nu ̈v nq] D‡j­L Ki“b KZ evi |____|____| DËi w`‡Z Abxnv Rvwb bv

bv

DËi w`‡Z Abxnv

Rvwb bv

3. MZ 30 w`‡b, Avcwb wK Dc‡i Dwj­wLZ msMVb ̧‡jv Qvov Ab ̈ †Kv‡bv msMV‡bi mfvq †hvM w`‡q‡Qb hviv

wbivg‡q mvnvh ̈ K‡i?

nu ̈v [hw` nu ̈v nq] D‡j­L Ki“b KZ evi |____|____| DËi w`‡Z Abxnv Rvwb bv

bv

DËi w`‡Z Abxnv

Rvwb bv

4. MZ 30 w`‡b, Avcbvi cwiev‡ii †Kv‡bv m`m ̈ Ges/A_ev eÜz‡`i mv‡_ wK Avcbvi †hvMv‡hvM n‡q‡Q hviv

Avcbvi wbivg‡q mnvqZv Ki‡Z Pvb?

nu ̈v

bv

DËi w`‡Z Abxnv

Rvwb bv

5. Avcwb mgm ̈vq co‡j Kvi Kv‡Q hvb? [ïaygvÎ GKwU wbe©vPb Ki“b|]

Kv‡iv Kv‡Q bq

ag©xq †bZv 

cwiev‡ii m`m ̈

eÜz

DËi w`‡Z Abxnv

Rvwb bv

Ab ̈vb ̈ (D‡j­L Ki“b) __________________________________
CSAT_GPRA_Client_Outcome_Instrument 18 v5.1

I. d‡jvAv‡ci Ae ̄’v

[ïaygvÎ d‡jvAv‡ci mgq K¬v‡q›U m¤ú‡K© Kg©m~wPi Kg©x‡`i Øviv wi‡cvU©K...Z|]

1. K¬v‡q‡›Ui d‡jvAv‡ci Ae ̄’v Kx? [GwU GKwU Avek ̈K AvB‡Ug: ca‡hvR ̈ bq, DËi w`‡Z Abxnv, Rvwb bv, Ges 

†bB, ManY Kiv n‡e bv]

01 = wba©vwiZ mg‡qi Av‡M gviv †M‡Qb

11 = wba©vwiZ mg‡qi g‡a ̈ mv¶vrKvi m¤úbœ K‡i‡Qb

12 = wba©vwiZ mg‡qi evB‡i mv¶vrKvi m¤úbœ K‡i‡Qb

21 = Ae ̄’vb Rvbv †M‡Q, wKš‘ Abxnv caKvk K‡i‡Qb, mywbw`©ó bq

22 = Ae ̄’vb Rvbv †M‡Q, wKš‘ cawZôv‡b ca‡e‡ki my‡hvM cvIqv hvqwb

23 = Ae ̄’vb Rvbv †M‡Q, wKš‘ Ab ̈ †Kv‡bv Kvi‡Y †`Lv Kivi my‡hvM cvIqv hvqwb

24 = Ae ̄’vb Rvbv †M‡Q, wKš‘ caKí †_‡K wb‡R‡K caZ ̈vnvi K‡i‡Qb

31 = Ae ̄’vb Rvbv hvqwb,  ̄’vb e`j K‡i‡Qb

32 = Ae ̄’vb Rvbv hvqwb, Ab ̈vb ̈ (D‡j­L Ki“b) ________________________

2. K¬v‡q›U wK GL‡bv Avcbvi Kg©m~wP †_‡K †mev cv‡”Qb?

nu ̈v

bv

[hw` GUv GKUv d‡jvAvc mv¶vrKvi nq, Zvn‡j GLb eÜ Ki“b; mv¶vrKvi †kl n‡q‡Q|]
CSAT_GPRA_Client_Outcome_Instrument 19 v5.1

J. wWmvPv‡R©i Ae ̄’v

[ïaygvÎ wWmPv‡R©i mgq K¬v‡q›U m¤ú‡K© Kg©m~wPi Kg©x‡`i Øviv wi‡cvU©K...Z]

1. K¬v‡q›U‡K K‡e wWmPvR© Kiv n‡q‡Q?

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

 gvm w`b eQi

2. K¬v‡q‡›Ui wWmPv‡R©i Ae ̄’v Kx?

01 = m¤úbœ/DËxY©

02 = LvwiR

hw` K¬v‡q›U‡K LvwiR Kiv nq, Zvn‡j Lvwi‡Ri KviY Kx wQj? [GKwU DËi wbe©vPb Ki“b|]

01 = Kg©x‡`i civg‡k©i wei“‡× wbR B”Qvq P‡j †M‡Qb, m‡š—vlRbK AMaMwZ wQj

02 = Kg©x‡`i civg‡k©i wei“‡× wbR B”Qvq P‡j †M‡Qb, m‡š—vlRbK AMaMwZ QvovB

03 = AskManY bv Kivi Kvi‡Y B”Qvi wei“‡× LvwiR Kiv n‡q‡Q

04 = wbqgÑKvbyb f1⁄2 Kivi Kvi‡Y B”Qvi wei“‡× LvwiR Kiv n‡q‡Q

05 = Ab ̈ †Kv‡bv Kg©m~wP ev Ab ̈ cwi‡levi Rb ̈ mycvwik Kiv n‡q‡Q, m‡š—vlRbK AMaMwZ wQj

06 = Ab ̈ †Kv‡bv Kg©m~wP ev Ab ̈ cwi‡levi Rb ̈ mycvwik Kiv n‡q‡Q, m‡š—vlRbK AMaMwZ wQj bv

07 = wPwKrmv/wbqvgqKvjxb mg‡q K...Z Aciv‡ai Rb ̈ Kvivi“× n‡q‡Qb, m‡š—vlRbK AMaMwZ wQj

08 = wPwKrmv/wbqvgqKvjxb mg‡q K...Z Aciv‡ai Rb ̈ Kvivi“× n‡q‡Qb, m‡š—vlRbK AMaMwZ wQj bv

09 = wPwKrmv/wbqvgq Kvh©μ‡g ca‡e‡ki Av‡M K...Z Aciv‡ai c‡ivqvbv ev Awf‡hv‡Mi Rb ̈ Kvivi“× n‡q‡Qb, m‡š—vlRbK 

AMaMwZ wQj

10 = wPwKrmv/wbqvgq Kvh©μ‡g ca‡e‡ki Av‡M K...Z Aciv‡ai c‡ivqvbv ev Awf‡hv‡Mi Rb ̈ Kvivi“× n‡q‡Qb, m‡š—vlRbK 

AMaMwZ wQj bv

11 =  ̄^v ̄’ ̈MZ Kvi‡Y Av‡iKwU cawZôv‡b  ̄’vbvš—i Kiv n‡q‡Q

12 = g„Z ̈z

13 = Ab ̈vb ̈ (D‡j­L Ki“b)__________________________________ 

3. Kg©m~wPwU wK GB K¬v‡q‡›Ui HIVÑGi cix¶v K‡i‡Q?

nu ̈v [mivmwi †mKkb KÑ†Z P‡j hvb|]

bv [J4ÑG hvb|]

4. [hw` bv nq] Kg©m~wPwU wK GB K¬v‡q›U‡K GB cix¶vi Rb ̈ civgk© w`‡q‡Q?

nu ̈v

bv
CSAT_GPRA_Client_Outcome_Instrument 20 v5.1

K. M„nxZ †mevmg~n

[ïaygvÎ wWmPv‡R©i mgq K¬v‡q›U m¤ú‡K© Kg©m~wPi Kg©x‡`i Øviv wi‡cvU©K...Z]

K¬v‡q‡›Ui wPwKrmv/Av‡ivM ̈jv‡fi mg‡q K¬v‡q›U‡K KZ 

w`b cwi‡lev †`qv n‡q‡Q Zv D‡j­L Ki“b| [†Kv‡bv 

cwi‡lev †`qv bv n‡j k~b ̈ wjLyb| wPwKrmvi ai‡bi 

Rb ̈ Avcbvi Kgc‡¶ GK w`b _vK‡Z n‡e|]

wPwKrmvi aib w`b

1. †Km e ̈e ̄’vcbv |___|___|___|

2. w`evKvjxb wPwKrmv |___|___|___|

3. fwZ© nIqv †ivMx/nvmcvZvj (gv`Kvkw3

wbivgq e ̈ZxZ) |___|___|___|

4. ewnwe©fvMxq †ivMx |___|___|___|

5. AvDUwiP |___|___|___|

6. wbweo ewnwe©fvMxq †ivMx |___|___|___|

7. †g_v‡Wvb |___|___|___|

8. AvevwmK/cybe©vmb |___|___|___|

9. gv`Kvkw3 wbivgq (ïay GKwU †e‡Q wbb):

A. nvmcvZv‡j fwZ© nIqv †ivMx |___|___|___|

B. wd« ÷ ̈vwÛs AvevwmK |___|___|___|

C. ewnwe©fvMxq †ivMx‡`i gv`Kvkw3 wbivgq |___|___|___|

10. cieZ©x cwiPh©v |___|___|___|

11. wbivg‡q mnvqZv |___|___|___|

12. Ab ̈vb ̈ (D‡j­L Ki“b) ________________ |___|___|___|

K¬v‡q‡›Ui wPwKrmv/Av‡ivM ̈jv‡fi mg‡q K¬v‡q›U‡K 

KqwU †mkb †`qv n‡q‡Q Zv D‡j­L Ki“b| [†Kv‡bv 

cwi‡lev †`qv bv n‡j k~b ̈ wjLyb|]

wPwKrmv †mev †mkb

[SBIRT gÄzwi: 1 †_‡K 4 ch©š— GKwU wPwKrmv †mevi 

Rb ̈ Avcbvi Kgc‡¶ GKwU †mkb _vK‡Z n‡e|]

1. w ̄Œwbs |___|___|___|

2. msw¶ß n ̄—‡¶c |___|___|___|

3. msw¶ß wPwKrmv |___|___|___|

4. wPwKrmvi Rb ̈ †idvi Kiv |___|___|___|

5. g~j ̈vqb |___|___|___|

6. wPwKrmv/wbivg‡qi cwiKíbv |___|___|___|

7. e ̈w3MZ civgk© †mev |___|___|___|

8. `jMZ civgk© †mev |___|___|___|

9. cvwievwiK/ˆeevwnK civgk© |___|___|___|

10. hyMcr wPwKrmv/wbivgq †mev |___|___|___|

11. IlyawfwËK n ̄—‡¶c |___|___|___|

12. HIV/GBWm m¤úwK©Z civgk© |___|___|___|

13. Ab ̈vb ̈ wPwKrmv †mev

(D‡j­L Ki“b) _____________________ |___|___|___|

†Km e ̈e ̄’vcbv cwi‡lev †mkb

1. cvwievwiK †mev (we‡q msμvš— wk¶v,

wcZ...Z¡/gvZ...Z¡, wkï Dbœqb †mev mn) |___|___|___|

2. wkï cwiPh©v |___|___|___|

3. Kg©ms ̄’vb msμvš— †mev

A. cavKÑKg©ms ̄’vb |___|___|___|

B. Kg©ms ̄’vb msμvš— †KvwPs |___|___|___|

4. e ̈w3MZ cwi‡levi mgš^q |___|___|___|

5. cwienb |___|___|___|

6. HIV/GBWm welqK cwi‡lev |___|___|___|

7. mnvqZvg~jK μvwš—Kvjxb gv`KÑgy3 Avevmb

†mev |___|___|___|

8. Ab ̈vb ̈ †Km e ̈e ̄’vcbv cwi‡lev

(D‡j­L Ki“b)_____________________ |___|___|___|

wPwKrmv †mev †mkb

1. wPwKrmv cwiPh©v |___|___|___|

2. A ̈vj‡Kvnj/gv`K cix¶v |___|___|___|

3. HIV/GBWm wPwKrmv mnvqZv I cix¶v |___|___|___|

4. Ab ̈vb ̈ wPwKrmv †mev

(D‡j­L Ki“b)_____________________ |___|___|___|

cwiPh©v cieZ©x †mev †mkb

1. Ae ̈vnZ cwiPh©v |___|___|___|

2. cybivq wjß nIqv cawZ‡iva |___|___|___|

3. wbivg‡qi †KvwPs |___|___|___|

4.  ̄^q¤¢i †Mvôx I mnvqZv `j |___|___|___|

5. Ava ̈vwZ¥K mnvqZv |___|___|___|

6. Ab ̈vb ̈ cwiPh©v cieZ©x †mev

(D‡j­L Ki“b)_____________________ |___|___|___|

wk¶v cwi‡lev †mkb

1. gv`‡Ki Ace ̈envi m¤úwK©Z wk¶v |___|___|___|

2. HIV/GBWm m¤úwK©Z wk¶v |___|___|___|

3. Ab ̈vb ̈ wk¶v cwi‡lev

(D‡j­L Ki“b)_____________________ |___|___|___|

m1⁄2xiÑØvivÑm1⁄2xi wbivgq mnvqZv 

cwi‡lev †mkb

1. m1⁄2x‡`i †KvwPs ev civgk© |___|___|___|

2. evm ̄’vb mnvqZv |___|___|___|

3. A ̈vj‡KvnjÑ I gv`KÑgy3 mgvRKg© |___|___|___|

4. Z_ ̈ I mycvwik |___|___|___|

5. m1⁄2xiÑØvivÑm1⁄2xi Ab ̈vb ̈ wbivgq mnvqZv

†mev

(D‡j­L Ki“b)_____________________ |___|___|___|