Attachment 7 - CSATGPRATool.pdf

Form Approved OMB No. 0930-0208

Expiration Date: 03/31/2025

Substance Abuse and Mental Health Services Administration

(SAMHSA)

Center for Substance Abuse Treatment (CSAT)

Government Performance and Results Act (GPRA)

Client Outcome Measures for Discretionary Programs August 2022

Public reporting burden for this collection of information is estimated to average 36 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information, if all items are asked of a client/participant; to the extent that providers already obtain much of this information as part of their ongoing client/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 SAMHSA Reports Clearance Officer, Room 15E57A, 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 OMB control number. The control number for this project is 0930-0208.

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Table of Contents

A. RECORD MANAGEMENT

A. RECORD MANAGEMENT - DEMOGRAPHICS

B. SUBSTANCE USE AND PLANNED SERVICES

C. LIVING CONDITIONS

D. EDUCATION, EMPLOYMENT, AND INCOME

E. LEGAL

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY

G. SOCIAL CONNECTEDNESS

H1. PROGRAM SPECIFIC QUESTIONS

H2. PROGRAM SPECIFIC QUESTIONS

H3. PROGRAM SPECIFIC QUESTIONS

H4. PROGRAM SPECIFIC QUESTIONS

H5. PROGRAM SPECIFIC QUESTIONS

H6. PROGRAM SPECIFIC QUESTIONS

H7. PROGRAM SPECIFIC QUESTIONS

H8. PROGRAM SPECIFIC QUESTIONS

H9. PROGRAM SPECIFIC QUESTIONS

H10. PROGRAM SPECIFIC QUESTIONS

I. FOLLOW-UP STATUS

J. DISCHARGE STATUS

K. SERVICES RECEIVED UNDER GRANT FUNDING

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A. RECORD MANAGEMENT

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

Client Description by Grant Type:

Treatment grant client Client in recovery grant

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

Interview Type [CIRCLE ONLY ONE TYPE.]

Intake [GO TO INTERVIEW DATE.]

3-month follow-up [FOR SELECT PROGRAMS]

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

[IF NO, GO DIRECTLY TO SECTION I.]

6-month follow-up → → → 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

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

1. What is your birth month and year?

Month Year

REFUSED

2. What do you consider yourself to be?

Male Female Transgender (Male to Female) Transgender (Female to Male) Gender non-conforming Other (SPECIFY) _____________

REFUSED

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

Yes No [SKIP TO QUESTION 4]

REFUSED [SKIP TO QUESTION 4]

3a. 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.

Black or African American White American Indian Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Other (SPECIFY)_____________ _______________________________

REFUSED

5. Do you speak a language other than English at home?

Yes No [SKIP TO QUESTION 6]

REFUSED [SKIP TO QUESTION 6]

5a. What is this language?

Spanish Other (SPECIFY) ___________

6. Do you think of yourself as… [YOU MAY INDICATE MORE THAN ONE.]

Straight Or Heterosexual Homosexual (Gay Or Lesbian) Bisexual Queer, Pansexual, And/Or Questioning Asexual Other (SPECIFY) ___________________________________

REFUSED

7. What is your relationship status?

Married Single Divorced Separated Widowed In a relationship In multiple relationships

REFUSED

8. Are you currently pregnant?

Yes No Do not know

REFUSED

9. Do you have children? [Refers to children both living and/or who may have died]

Yes No [SKIP TO QUESTION 10]

REFUSED [SKIP TO QUESTION 10]

9a. How many children under the age of 18 do you have?

|____|____| REFUSED

9b. Are any of your children, who are under the age of 18, living with someone else due to a court’s intervention? [THE VALUE IN ITEM A9b CANNOT EXCEED THE VALUE IN A9a.]

Yes Number of children removed from client’s care |____|____| No [SKIP TO QUESTION 10]

REFUSED [SKIP TO QUESTION 10]

9c. Have you been reunited with any of your children, under the age of 18, who have been previously removed from your care? [THE VALUE IN ITEM A9c CANNOT EXCEED THE VALUE IN A9a.]

Yes Number of children with whom the client has been reunited |____|____| No

REFUSED

10. Have you ever served in the Armed Forces, in the Reserves, in the National Guard, or in other Uniformed Services? [IF SERVED] What area, the Armed Forces, Reserves, National Guard, or other did you serve?

No Yes, In The Armed Forces Yes, In The Reserves Yes, In The National Guard Yes, Other Uniformed Services [Includes NOAA, USPHS]

REFUSED

11. How long does it take you, on average, to travel to the location where you receive services provided by this grant?

Half an hour or less Between half an hour and one hour Between one hour and one and a half hours Between one and a half hours and two hours Two hours or more

B. SUBSTANCE USE AND PLANNED SERVICES

1. USING THE TABLE BELOW, PLEASE INDICATE THE FOLLOWING:

A. THE NUMBER OF DAYS, IN THE PAST 30 DAYS, THAT THE CLIENT REPORTS USING A

SUBSTANCE.

[DO NOT READ TO CLIENT] The client should be encouraged to list the substances on their own. If they are unsure, the list from the table below can be read to the client. Please note that not all substance use is considered harmful or illicit – it may be that a substance is prescribed by a licensed provider, or that the client uses the substance in accordance with official, national safety guidelines. In such instances, clarification from the client should be sought, but if the substance is only taken as prescribed or used on each occasion in accordance with official, national safety guidelines, then it is not considered misuse. If no use of a listed substance is reported, please enter a zero (‘0’) in the corresponding ‘Number of Days Used’ column. If the client refuses to answer the question, then select “REFUSED”.

B. THE ROUTE BY WHICH THE SUBSTANCE IS USED.

[DO NOT READ TO CLIENT] Mark one route only for each substance used. But, if the client identifies more than one route, choose the corresponding route with the highest associated number value (numbers 1 – 6).

Responses should capture the past 30 days of use.

During the past 30 days, how many days have you used any substance, and how do you take the substance?

A. Number of Days Used

B. Route 1.

Oral 2.

Intranasal 3.

Vaping 4.

Smoking 5.

Non-IV Injection 6.

Intravenous (IV) Injection 0.

Other

a. Alcohol

1. Alcohol |___|___| |___|

2. Other (SPECIFY) |___|___| |___|

b. Opioids

1. Heroin |___|___| |___|

2. Morphine |___|___| |___|

3. Fentanyl (Prescription Diversion Or

Illicit Source) |___|___| |___|

4. Dilaudid |___|___| |___|

5. Demerol |___|___| |___|

6. Percocet |___|___| |___|

7. Codeine |___|___| |___|

8. Tylenol 2, 3, 4 |___|___| |___|

9. OxyContin/Oxycodone |___|___| |___|

10. Non-prescription methadone |___|___| |___|

11. Non-prescription buprenorphine |___|___| |___|

12. Other (SPECIFY) |___|___| |___|

c. Cannabis

1. Cannabis (Marijuana) |___|___| |___|

2. Synthetic Cannabinoids |___|___| |___|

Days Used

B. Route 1.

Oral 2.

Intranasal 3.

Vaping 4.

Smoking 5.

Non-IV Injection 6.

Intravenous (IV) Injection 0.

Other

3. Other (SPECIFY) |___|___| |___|

d. Sedative, Hypnotic, or Anxiolytics

1. Sedatives |___|___| |___|

2. Hypnotics |___|___| |___|

3. Barbiturates |___|___| |___|

4. Anxiolytics/Benzodiazepines |___|___| |___|

5. Other (SPECIFY) |___|___| |___|

e. Cocaine

1. Cocaine |___|___| |___|

2. Crack |___|___| |___|

f. Other Stimulants

1. Methamphetamine |___|___| |___|

2. Stimulant medications |___|___| |___|

g. Hallucinogens & Psychedelics

1. PCP |___|___| |___|

2. MDMA |___|___| |___|

3. LSD |___|___| |___|

4. Mushrooms |___|___| |___|

5. Mescaline |___|___| |___|

6. Salvia |___|___| |___|

7. DMT |___|___| |___|

8. Other (SPECIFY) |___|___| |___|

h. Inhalants

1. Inhalants |___|___| |___|

2. Other (SPECIFY) |___|___| |___|

i. Other Psychoactive Substances

1. Non-prescription GHB |___|___| |___|

2. Ketamine |___|___| |___|

3. MDPV/Bath Salts |___|___| |___|

4. Kratom |___|___| |___|

5. Khat |___|___| |___|

6. Other tranquilizers |___|___| |___|

7. Other downers |___|___| |___|

8. Other sedatives |___|___| |___|

9. Other hypnotics |___|___| |___|

10. Other (SPECIFY) |___|___| |___|

j. Tobacco and Nicotine

1. Tobacco |___|___| |___|

Days Used

B. Route 1.

Oral 2.

Intranasal 3.

Vaping 4.

Smoking 5.

Non-IV Injection 6.

Intravenous (IV) Injection 0.

Other

2. Nicotine (Including Vape Products) |___|___| |___|

2. Have you been diagnosed with an alcohol use disorder, if so which FDA-approved medication did you receive for the treatment of this alcohol use disorder in the past 30 days? [CHECK ALL THAT APPLY.]

Naltrexone [IF RECEIVED] Specify how many days received |___|___| Extended‒release Naltrexone [IF RECEIVED] Specify how many doses received |___|___| Disulfiram [IF RECEIVED] Specify how many days received |___|___| Acamprosate [IF RECEIVED] Specify how many days received |___|___|

DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED ALCOHOL USE

DISORDER

CLIENT DOES NOT REPORT SUCH A DIAGNOSIS

3. Have you been diagnosed with an opioid use disorder, if so which FDA-approved medication did you receive for the treatment of this opioid use disorder in the past 30 days? [CHECK ALL THAT APPLY.]

Methadone [IF RECEIVED] Specify how many days received |___|___| Buprenorphine [IF RECEIVED] Specify how many days received |___|___| Naltrexone [IF RECEIVED] Specify how many days received |___|___| Extended‒release Naltrexone [IF RECEIVED] Specify how many doses received |___|___|

DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED OPIOID USE DISORDER

4. Have you been diagnosed with a stimulant use disorder, if so which evidence-based interventions did you receive for the treatment of this disorder in the past 30 days? [CHECK ALL THAT APPLY.]

Contingency Management [IF RECEIVED] Specify how many days received |___|___| Community Reinforcement [IF RECEIVED] Specify how many days received |___|___| Cognitive Behavioral Therapy [IF RECEIVED] Specify how many days received |___|___| Other evidence-based intervention [IF RECEIVED] Specify how many days received |___|___|

DID NOT RECEIVE ANY INTERVENTION FOR A DIAGNOSED STIMULANT USE DISORDER

5. Have you been diagnosed with a tobacco use disorder, if so which FDA-approved medication did you receive for the treatment of this tobacco use disorder in the past 30 days? [CHECK ALL THAT APPLY.]

Nicotine Replacement [IF RECEIVED] Specify how many days received |___|___| Bupropion [IF RECEIVED] Specify how many days received |___|___| Varenicline [IF RECEIVED] Specify how many days received |___|___|

DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED TOBACCO USE

DISORDER

6. In the past 30 days, did you experience an overdose or take too much of a substance that resulted in needing supervision or medical attention?

Yes [IF YES, SPECIFY BELOW, IN QUESTION 7] No [IF NO, SKIP TO QUESTION 8]

REFUSED [SKIP TO QUESTION 8]

7. In the past 30 days, after taking too much of a substance or overdosing, what intervention did you receive?

You may indicate more than one.

Naloxone (Narcan) Care in an Emergency Department Care from a Primary Care Provider Admission to a hospital Supervision by someone else Other (SPECIFY) ______________________________

8. Not including this current episode, how many times in your life have you been treated at an inpatient or outpatient facility for a substance use disorder?

One time Two times Three times Four times Five times Six or more times Never [SKIP TO QUESTION 10]

REFUSED [SKIP TO QUESTION 10]

9. Approximately when was the last time you received inpatient or outpatient treatment for a substance use disorder?

Less than 6 months ago Between 6 months and one year ago One to two years ago Two to three years ago Three to four years ago Five or more years ago

10. Have you ever been diagnosed with a mental health illness by a health care professional?

Yes No [SKIP TO QUESTION 11]

REFUSED [SKIP TO QUESTION 11]

10a. PLEASE ASK THE CLIENT TO SELF-REPORT THEIR MENTAL HEALTH ILLNESSES AS

LISTED IN THE TABLE BELOW. THE CLIENT SHOULD BE ENCOURAGED TO REPORT

THEIR OWN MENTAL HEALTH ILLNESSES BUT IF PREFERRED, THE LIST CAN BE

READ TO THE CLIENT. PLEASE INDICATE ALL THAT APPLY.

SELF-REPORTED

Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders Brief psychotic disorder Delusional disorder Schizoaffective disorders Schizophrenia Schizotypal disorder Shared psychotic disorder Unspecified psychosis Mood [affective] disorders Bipolar disorder Major depressive disorder, recurrent

SELF-REPORTED

Major depressive disorder, single episode Manic episode Persistent mood [affective] disorders Unspecified mood [affective] disorder Phobic Anxiety and Other Anxiety Disorders Agoraphobia without panic disorder Agoraphobia with panic disorder Agoraphobia, unspecified Generalized anxiety disorder Panic disorder Phobic anxiety disorders Social phobias (Social anxiety disorder) Specific (isolated) phobias Obsessive-compulsive disorders Excoriation (skin-picking) disorder Hoarding disorder Obsessive-compulsive disorder Obsessive-compulsive disorder with mixed obsessional thoughts and acts Reaction to severe stress and adjustment disorders Acute stress disorder; reaction to severe stress, and adjustment disorders Adjustment disorders Body dysmorphic disorder Dissociative and conversion disorders Dissociative identity disorder Post traumatic stress disorder Somatoform disorders Behavioral syndromes associated with physiological disturbances and physical factors Eating disorders Sleep disorders not due to a substance or known physiological condition Disorders of adult personality and behavior Antisocial personality disorder Avoidant personality disorder Borderline personality disorder Dependent personality disorder Histrionic personality disorder Intellectual disabilities Obsessive-compulsive personality disorder Other specific personality disorders Paranoid personality disorder Personality disorder, unspecified Pervasive and specific developmental disorders Schizoid personality disorder o NONE OF THE ABOVE

[FOLLOW-UP AND DISCHARGE INTERVIEWS: GO TO SECTION C. AT INTAKE, CONTINUE WITH THE

FOLLOWING QUESTIONS]

11. Was the client screened by your program, using an evidence-based tool or set of questions, for co-occurring mental health and/or substance use disorders?

Yes No [SKIP TO QUESTION 12]

11a. Did the client screen positive for co-occurring mental health and substance use disorders?

Yes No

11b. [IF YES TO QUESTION 11a] Was the client referred for further assessment for a co-occurring mental health and substance use disorder?

No

12. PLANNED SERVICES PROVIDED UNDER GRANT FUNDING [REPORTED BY PROGRAM STAFF

ONLY AT INTAKE/BASELINE.]

Identify the services you plan to provide to the client during the client’s course of treatment/recovery. [MARK

ONLY THE CIRCLE CORRESPONDING TO THE PLANNED

SERVICE THAT WILL BE PROVIDED UNDER THE CURRENT

GRANT. MARK ALL THAT APPLY IN EACH SECTION.]

Modality

[SELECT AT LEAST ONE MODALITY.]

1. Case Management

2. Intensive Outpatient Treatment

3. Inpatient/Hospital (Other Than Withdrawal

Management)

4. Outpatient Therapy

5. Outreach

6. Medication A. Methadone B. Buprenorphine C. Naltrexone – Short Acting D. Naltrexone – Long Acting E. Disulfiram F. Acamprosate G. Nicotine Replacement H. Bupropion I. Varenicline

7. Residential/Rehabilitation

8. Withdrawal Management (Select Only One)

A. Hospital Inpatient B. Free Standing Residential C. Ambulatory Detoxification

9. After Care

10. Recovery Support

11. Other (Specify) ________________________

[SELECT AT LEAST ONE SERVICE.]

Treatment Services

[SBIRT GRANTS: YOU MUST PROVIDE AT

LEAST 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 Planning

7. Recovery Planning

8. Individual Counseling

9. Group Counseling

10. Contingency Management

11. Community Reinforcement

12. Cognitive Behavioral Therapy

13. Family/Marriage Counseling

14. Co-Occurring Treatment Services

15. Pharmacological Interventions

16. HIV/AIDS Counseling

17. Cultural Interventions/Activities

18. Other Clinical Services

(Specify) _____________________________

Case Management Services

1. Family Services (E.g. 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 Services A. If HIV Neg, Pre-Exposure Prophylaxis B. If HIV Neg, Post-Exposure Prophylaxis C. If HIV Positive, HIV Treatment

7. Transitional Drug-Free Housing Services

8. Housing Support

9. Health Insurance Enrollment

10. Other Case Management Services

(Specify) ____________________________

Medical Services

1. Medical Care

2. Alcohol/Drug Testing

3. OB/GYN Services

4. HIV/AIDS Medical Support & Testing

5. Dental Care

6. Viral Hepatitis Medical Support & Testing

7. Other STI Support & Testing

8. Other Medical Services

(Specify) ____________________________

After Care Services

1. Continuing Care

2. Relapse Prevention

3. Recovery Coaching

4. Self-Help and Mutual Support Groups

5. Spiritual Support

6. Other After Care Services

(Specify) ____________________________

Education Services

1. Substance Use Education

2. HIV/AIDS Education

3. Naloxone Training

4. Fentanyl Test Strip Training

5. Viral Hepatitis Education

6. Other STI Education Services

7. Other Education Services

(Specify) ____________________________

Recovery Support Services

1. Peer Coaching or Mentoring

2. Vocational Services

3. Recovery Housing

4. Recovery Planning

5. Case Management Services to Specifically

Support Recovery

6. Alcohol- and Drug-Free Social Activities

7. Information and Referral

8. Other Recovery Support Services

(Specify)_________________________

9. Other Peer-to-Peer Recovery Support Services

(Specify) ____________________________

C. 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: [IF HOUSED, CHECK APPROPRIATE SUBCATEGORY:] Own/Rental Apartment, Room, Trailer, Or House Someone Else’s Apartment, Room, Trailer, Or House (including couch surfing) Dormitory/College Residence Halfway House or Transitional Housing Residential Treatment Recovery Residence/Sober Living Other Housed (SPECIFY) ________________________________________________________________

REFUSED

2. Do you currently live with any person who, over the past 30 days, has regularly used alcohol or other substances?

Yes No No, lives alone

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? [IF CLIENT IS INCARCERATED, CODE D1 AS “NOT ENROLLED.”]

NOT ENROLLED

ENROLLED, FULL TIME

ENROLLED, PART TIME

REFUSED

2. 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

VOCATIONAL/TECHNICAL (VOC/TECH) DIPLOMA

SOME COLLEGE OR UNIVERSITY

BACHELOR’S DEGREE (FOR EXAMPLE: BA, BS)

GRADUATE WORK/GRADUATE DEGREE

OTHER (SPECIFY)____________________________________

REFUSED

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.] [IF CLIENT IS INCARCERATED AND HAS NO WORK OUTSIDE OF JAIL,

CODE D3 AS “NOT LOOKING FOR WORK.”]

EMPLOYED, FULL TIME (35+ HOURS PER WEEK, OR WOULD BE, IF NOT FOR LEAVE OR AN

EXCUSED ABSENCE)

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

4. Do you, individually, have enough money to pay for the following living expenses? Choose all that apply.

Food Clothing Transportation Rent/Housing Utilities (Gas/Water/Electric) Telephone Connection (Cell or Landline) Childcare Health Insurance

5. What is your personal annual income, meaning the total pre-tax income from all sources, earned in the past year?

$0 to $9,999 $10,000 to $14,999 $15,000 to $19,999 $20,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $199,999 $200,000 or more

E. LEGAL

1. In the past 30 days, how many times have you been arrested? [IF THE CLIENT INDICATES NO

ARRESTS IN THE PAST 30 DAYS, BUT IS INCARCERATED AT THE TIME OF THE INTERVIEW,

MARK CURRENTLY INCARCERATED]

|____|____| TIMES REFUSED Currently Incarcerated

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

Yes No

REFUSED

3. Are you currently on parole or probation or intensive pretrial supervision?

Probation Parole Intensive Pretrial Supervision No

REFUSED

4. Do you currently participate in a drug court program or are you in a deferred prosecution agreement?

Drug court program Deferred prosecution agreement No, neither of these

F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT/RECOVERY

1. How would you rate your quality of life over the past 30 days?

Very poor Poor Neither poor nor good Good Very good

REFUSED

2. In the past 30 days, how many days have you [ENTER ‘O’ IN DAYS IF THE CLIENT REPORTS THAT

THEY HAVE NOT EXPERIENCED THE CONDITION. SELECT REFUSED FOR NO RESPONSE]:

Days REFUSED 2a. Experienced serious depression |____|____| 2b. Experienced serious anxiety or tension |____|____| 2c. Experienced hallucinations |____|____| 2d. Experienced trouble understanding, concentrating, or remembering |____|____| 2e. Experienced trouble controlling violent behavior |____|____| 2f. Attempted suicide |____|____| 2g. Been prescribed medication for psychological/emotional problem |____|____|

[IF CLIENT REPORTS 1 OR MORE DAYS TO ANY QUESTION IN #2, PLEASE ENSURE THAT THEY

ARE SEEN BY A LICENSED PROFESSIONAL AS SOON AS POSSIBLE.]

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

Not at all Slightly Moderately Considerably Extremely

NO REPORTED MENTAL HEALTH COMPLAINTS IN THE PAST 30 DAYS

REFUSED ____________________________________________________________________________

4. In the past 30 days, where have you gone to receive medical care? You may select more than one response.

Primary Care Provider Urgent Care The Emergency Department A specialist doctor No care was sought Other (SPECIFY) _____________________________

5. Do you currently have medical/health insurance?

Yes No [GO TO NEXT SECTION]

REFUSED [GO TO NEXT SECTION]

5a. What type of insurance do you have [CHECK ALL THAT APPLY]?

Medicare Medicaid Private Insurance or Employer Provided TRICARE or other military health care An assistance program [for example, a medication assistance program] Any other type of health insurance or health coverage plan (SPECIFY)______________________

G. SOCIAL CONNECTEDNESS

1. In the past 30 days, did you attend any voluntary mutual support groups for recovery? In other words, did you participate in a non-professional, peer-operated organization that assists individuals who have addiction-related problems such as: Alcoholics Anonymous, Narcotics Anonymous, Secular Organization for Sobriety, Women for Sobriety, religious/faith-affiliated recovery mutual support groups, etc.?

Attendance could have been in person or virtual.

Yes [IF YES] Specify How Many Times |____|____| REFUSED No

REFUSED

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

Yes No

REFUSED

3. How satisfied are you with your personal relationships?

Very Dissatisfied Dissatisfied Neither Satisfied nor Dissatisfied Satisfied Very Satisfied

REFUSED

4. In the past 30 days did you realize that you need to change those social connections or places that negatively impact your recovery?

Yes

H. PROGRAM SPECIFIC QUESTIONS: YOU ARE NOT RESPONSIBLE FOR COLLECTING DATA ON ALL

SECTION H QUESTIONS. YOUR GPO HAS PROVIDED YOU WITH GUIDANCE ON WHICH SPECIFIC

SECTION H QUESTIONS YOU ARE TO COMPLETE. IF YOU HAVE ANY QUESTIONS, PLEASE

CONTACT YOUR GPO.

H1. PROGRAM SPECIFIC QUESTIONS

[QUESTION 1 SHOULD BE REPORTED BY GRANTEE STAFF AT FOLLOW-UP AND DISCHARGE]

1. Which of the following occurred for the client, subsequent to receiving treatment? [CHECK ALL THAT

APPLY.]

Client was reunited with child (or children) 1a. With Agency Supervision 1b. Without Agency Supervision Client avoided out of home placement for child (or children) None of the above

H2. PROGRAM SPECIFIC QUESTIONS

[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]

1. Did the [INSERT GRANTEE NAME] help you obtain any of the following benefits? [CHECK ALL THAT

APPLY.]

Private Health Insurance Medicaid Medicare

SSI/SSDI

TANF

SNAP

Other (SPECIFY)

NONE OF THE ABOVE

H3. PROGRAM SPECIFIC QUESTIONS

[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE.]

1. Have you achieved any of the following since you began receiving services or supports from [INSERT GRANTEE NAME]? IF YES, Do you believe that the services you received from [INSERT GRANTEE NAME] helped you with this achievement?

Achieved? [IF YES], Do you believe that the services you received from [INSERT GRANTEE NAME] helped you with this achievement?

1a. Enrolled in school Yes

No

REFUSED

Yes No

REFUSED

1b. Enrolled in vocational training Yes No

REFUSED

Yes No

1c. Currently employed

REFUSED

Yes No

1d. Living in stable housing

REFUSED

Yes

H4. PROGRAM SPECIFIC QUESTIONS

[QUESTION 1 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]

1. Please indicate the degree to which you agree or disagree with the following statements:

1a. Receiving treatment in a non-residential setting has enabled me to maintain parenting and family responsibilities while receiving treatment.

Strongly disagree Disagree Undecided Agree Strongly Agree

REFUSED

1b. As a result of treatment, I feel I now have the skills and support to balance parenting and managing my recovery.

Strongly disagree Disagree Undecided Agree Strongly Agree

H5. PROGRAM SPECIFIC QUESTIONS

1a. Receiving treatment in a residential setting without my child (or children) has enabled me to focus on my treatment without distractions of parenting and family responsibilities.

Strongly disagree Disagree Undecided Agree Strongly Agree

REFUSED

1b. As a result of treatment, I feel I now have the skills and support to balance parenting and managing my recovery.

Strongly disagree Disagree Undecided Agree

H6. PROGRAM SPECIFIC QUESTIONS

[QUESTION 1 SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOW-UP, AND

DISCHARGE.]

1. Please indicate which type of funding was/will be used to pay for the SBIRT services provided to this client.

[CHECK ALL THAT APPLY.]

Current SAMHSA grant funding Other federal grant funding State funding Client’s private insurance Medicaid/Medicare

TRICARE

Other (SPECIFY)____________________

[IF FOLLOW-UP OR DISCHARGE INTERVIEW, SKIP TO QUESTION 6.]

[QUESTIONS 2-5 SHOULD BE REPORTED BY GRANTEE STAFF ONLY AT INTAKE/BASELINE.]

2. When the SBIRT was administered, how did the client screen?

Negative Positive

3. What was their screening score?

3a. Alcohol Use Disorders Identification Test (AUDIT) = |____|____|

3b. CAGE = |____|____|

3c. Drug Abuse Screening Test (DAST) = |____|____|

3d. DAST-10 = |____|____|

3e. National Institute on Alcohol Abuse and Alcoholism (NIAAA) Guide = |____|____|

3f. Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)/Alcohol Subscore

3g. Other (SPECIFY) = |____|____|

4. Were they willing to continue their participation in SBIRT services?

5. If the client screened positive for substance misuse or a substance use disorder, was the client assigned to the following types of services? [IF CLIENT SCREENED NEGATIVE, SELECT “NO” FOR EACH

SERVICE BELOW.]

Yes No 5a. Brief Intervention 5b. Brief Treatment 5c. Referral to Treatment

[QUESTION 6 SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOW-UP AND

DISCHARGE.]

6. Did the client receive the following types of services?

Yes No 6a. Brief Intervention 6b. Brief Treatment 6c. Referral to Treatment

H7. PROGRAM SPECIFIC QUESTIONS

[ALL H7 QUESTIONS SHOULD BE ANSWERED BY THE CLIENT AT INTAKE/BASELINE, FOLLOW-UP

AND DISCHARGE.]

1. In the past 30 days, have you been sexually active?

Yes No [SKIP TO QUESTION 2] Not Permitted To Ask [SKIP TO QUESTION 2]

REFUSED [SKIP TO QUESTION 2]

Altogether, in the past 30 days, how many: Response REFUSED

1a. Sexual partners did you have? Number: |____|____|____| 1b. Did you engage in unprotected/condomless sex?

Yes No → [SKIP TO QUESTION 2] 1c. Were any of your partners:

1. Living with HIV and not taking HIV medications Yes No

2. A person who injects drugs Yes No

3. High on one or more substances Yes No

2. Are you currently taking Pre-Exposure Prophylaxis (PrEP) for HIV prevention, or are you taking medication for the treatment of HIV?

PrEP Treatment for HIV Neither

REFUSED

3. Did the program provide access to the following?

3a1. An HIV test?

Yes No [SKIP TO QUESTION 3b1] REFUSED [SKIP TO QUESTION 3b1]

3a2. Was this the first time that you had been tested for HIV?

Yes No [SKIP TO QUESTION 3a5] REFUSED [SKIP TO QUESTION 3a5]

3a3. Was HIV testing performed on-site or were you referred out for testing?

On-site [SKIP TO QUESTION 3a5] Referred out REFUSED [SKIP TO QUESTION 3a5]

3a4. Where was testing performed?

Primary Care Provider’s office Dedicated clinic VA Medical Center Health Center or Community Clinic Local Health Department Specialty Addiction Treatment Program Sexual Health Center A mobile testing service Other (SPECIFY) _________________

3a5. What was the result?

Positive Negative [SKIP TO QUESTION 3a12] Indeterminate REFUSED [SKIP TO QUESTION 3b1]

3a6. Did you receive confirmatory testing?

Yes No [SKIP TO QUESTION 3a8] REFUSED [SKIP TO QUESTION 3a8]

3a7. What was the result?

Positive Negative Indeterminate

3a8. Were you connected to HIV treatment services within 30 days of the positive test result?

No [SKIP TO QUESTION 3a10] REFUSED [SKIP TO QUESTION 3a10]

3a9. Where were you referred for ongoing treatment?

Primary Care Provider’s office Dedicated clinic VA Medical Center Health Center or Community Clinic Local Health Department Specialty Addiction Treatment Program Sexual Health Center Other (SPECIFY) _________________

3a10. Was rapid HIV testing offered to your substance-using and/or sexual partners?

Yes No [SKIP TO QUESTION 3b1] REFUSED [SKIP TO QUESTION 3b1]

3a11. What was the number of drug-using and/or sexual partners offered HIV testing?

1 [SKIP TO QUESTION 3b1] 2 [SKIP TO QUESTION 3b1] 3 [SKIP TO QUESTION 3b1] 4 or more [SKIP TO QUESTION 3b1] REFUSED [SKIP TO QUESTION 3b1]

3a12. Were you referred for Pre-Exposure Prophylaxis (PrEP) or Post-Exposure Prophylaxis (PEP), and/or were you referred for counseling about these interventions? [SELECT ALL THAT APPLY]

PrEP

PEP

Received Counseling Did not receive medications Did not receive counseling

REFUSED

3b1. Did you receive a Rapid Hepatitis C (HCV) test?

Yes No [SKIP TO QUESTION 3c1] REFUSED [SKIP TO QUESTION 3c1]

3b2. Was this test followed up with confirmatory Hepatitis C (HCV RNA) testing?

Yes No

3b3. What was the result of your HCV test?

Positive Negative [SKIP TO QUESTION 3c1] Indeterminate REFUSED [SKIP TO QUESTION 3c1]

3b4. Were you connected to Hepatitis C treatment services?

REFUSED

3c1. Did you receive a Hepatitis B (HBV) test?

Yes No [SKIP TO QUESTION 3d1] REFUSED [SKIP TO QUESTION 3d1]

3c2. What was the result of your HBV test?

Positive Negative [SKIP TO QUESTION 3d1] Indeterminate REFUSED [SKIP TO QUESTION 3d1]

3c3. Were you connected to Hepatitis B treatment services?

REFUSED

3d1. Was the client offered a Hepatitis A and B Vaccination?

Yes [GO TO SECTION I OR J/K] No

REFUSED [GO TO SECTION I OR J/K]

3d2. Was the client referred out for vaccination?

Yes

H8. PROGRAM SPECIFIC QUESTIONS [QUESTIONS 1, 2 AND 3 SHOULD BE ANSWERED BY THE

CLIENT AT FOLLOW-UP AND DISCHARGE]

1. Is peer support available at this program?

Yes No [SKIP TO QUESTION 3]

2. Have you achieved any of the following since you began receiving peer services from [INSERT GRANTEE NAME]? [IF YES], Do you believe that the services you received from [INSERT GRANTEE NAME] helped you with this achievement?

3. To what extent has this program improved your quality of life?

To a great extent Somewhat Very little Not at all

Achieved? [IF YES], Do you believe that the services you received from [INSERT GRANTEE NAME] helped you with this achievement?

2a. Enrolled in school Yes

No

REFUSED

Yes No

REFUSED

2b. Enrolled in vocational training Yes No

REFUSED

Yes No

2c. Currently employed

REFUSED

Yes No

REFUSED

2d. Living in stable housing Yes No

REFUSED

Yes

H9. PROGRAM SPECIFIC QUESTIONS

1a. The use of technology accessed through [INSERT GRANTEE NAME] has helped me communicate with my provider.

Strongly disagree Disagree Undecided Agree Strongly Agree

NOT APPLICABLE

1b. The use of technology accessed through [INSERT GRANTEE NAME] has helped me reduce my substance use.

Undecided Agree Strongly Agree

1c. The use of technology accessed through [INSERT GRANTEE NAME] has helped me manage my mental health symptoms.

Undecided Agree Strongly Agree

1d. The use of technology accessed through [INSERT GRANTEE NAME] has helped me support my recovery.

Undecided Agree Strongly Agree

H10. PROGRAM SPECIFIC QUESTIONS

[QUESTIONS 1 AND 1a SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOW-UP, AND DISCHARGE]

[QUESTION 1b SHOULD BE REPORTED BY GRANTEE STAFF AT FOLLOW-UP/DISCHARGE IF THE

CLIENT HAS BEEN REFERRED FOR SERVICES]

1. Did the client screen positive for, or have a history of, a mental health disorder?

Client screened positive Client screened negative [SKIP TO QUESTION 2] Client was not screened [SKIP TO QUESTION 2] Client has a positive history

1a. Was the client referred to mental health services?

Yes [SKIP TO QUESTION 2 IF INTAKE/BASELINE; ANSWER 1b IF FOLLOW-UP/DISCHARGE] No [SKIP TO QUESTION 2]

1b. Did the client receive mental health services?

[QUESTIONS 2 AND 2a SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOW-UP, AND DISCHARGE]

[QUESTION 2b SHOULD BE REPORTED BY GRANTEE STAFF AT FOLLOW-UP/DISCHARGE IF THE

CLIENT HAS BEEN REFERRED FOR SERVICES]

2. Did the client screen positive for, or have a history of, substance use disorder(s)?

Client screened positive Client screened negative [SKIP TO QUESTION 3 IF FOLLOW-UP/DISCHARGE] Client was not screened [SKIP TO QUESTION 3 IF FOLLOW-UP/DISCHARGE] Client has a positive history

2a. Was the client referred to substance use disorder services?

Yes [ANSWER 2b IF FOLLOW-UP/DISCHARGE] No [SKIP TO QUESTION 3 IF FOLLOW-UP/DISCHARGE]

[IF THIS IS AN INTAKE/BASELINE, SECTION H10 IS DONE.]

2b. Did the client receive substance use disorder services?

H10. PROGRAM SPECIFIC QUESTIONS (continued)

[QUESTION 3 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE]

3. Please indicate the degree to which you agree or disagree with the following statement: Receiving community-based services through [INSERT GRANTEE NAME] has helped me to avoid further contact with the police and the criminal justice system.

Strongly disagree Disagree Undecided Agree

I. FOLLOW-UP STATUS

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

1. Was the client able to be contacted for follow-up?

Yes No

2. 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) ________________________

3. Is the client still receiving services from your program?

Please complete Sections B, C, D, E, F, G and those sections of Section H assigned to your program.

[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 [SKIP TO QUESTION 3] 02 = Termination

2a. 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) __________________________________

3. Did the program order an HIV test for this client?

Yes [SKIP TO QUESTION 5] No

4. Did the program refer this client for HIV testing with another provider?

Yes No

5. Did the program provide Naloxone and/or Fentanyl Test Strips to this client at any time during their involvement in grant funded services?

Naloxone Fentanyl Test Strips Both Naloxone and Fentanyl Test Strips Neither

6. Is the client fully vaccinated against the virus that causes COVID-19?

Yes No, partially vaccinated with plans to receive the subsequent vaccination on time No, partially vaccinated with no plan to receive the subsequent vaccination No, client refused vaccination Refused to answer

K. SERVICES RECEIVED UNDER GRANT FUNDING [REPORTED BY PROGRAM STAFF ONLY AT DISCHARGE.]

1. 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. Intensive Outpatient Treatment |___|___|___|

3. Inpatient/Hospital (Other Than Withdrawal

Management) |___|___|___|

4. Outpatient Therapy |___|___|___|

5. Outreach |___|___|___|

6. Medication A. Methadone |___|___|___| B. Buprenorphine |___|___|___| C. Naltrexone – Short Acting |___|___|___| D. Naltrexone – Long Acting (Report 28 days for each one injection) |___|___|___| E. Disulfiram |___|___|___| F. Acamprosate |___|___|___| G. Nicotine Replacement |___|___|___| H. Bupropion |___|___|___| I. Varenicline |___|___|___|

7. Residential/Rehabilitation |___|___|___|

8. Withdrawal Management (Select Only 1):

A. Hospital Inpatient |___|___|___| B. Free Standing Residential |___|___|___| C. Ambulatory Detoxification |___|___|___|

9. After Care |___|___|___|

10. Recovery Support |___|___|___|

11. 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. YOU SHOULD HAVE AT LEAST ONE SESSION IN ONE

SERVICE CATEGORY.]

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 Planning |___|___|___|

7. Recovery Planning |___|___|___|

8. Individual Counseling |___|___|___|

9. Group Counseling |___|___|___|

10. Contingency Management |___|___|___|

11. Community Reinforcement |___|___|___|

12. Cognitive Behavioral Therapy |___|___|___|

13. Family/Marriage Counseling |___|___|___|

14. Co-Occurring Treatment Services |___|___|___|

15. Pharmacological Interventions |___|___|___|

16. HIV/AIDS Counseling |___|___|___|

17. Cultural Interventions/Activities |___|___|___|

18. Other Clinical Services

(Specify) ___________________________ |___|___|___|

Case Management Services Sessions

1. Family Services (E.g 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 Services & Counseling |___|___|___|

7. Transitional Drug-Free Housing Services |___|___|___|

8. Housing Support |___|___|___|

9. Health Insurance Enrollment |___|___|___|

10. Other Case Management Services

(Specify) ___________________________ |___|___|___|

Medical Services Sessions

1. Medical Care |___|___|___|

2. Alcohol/Drug Testing |___|___|___|

3. OB/GYN Services |___|___|___|

4. HIV/ AIDS Medical Support & Testing |___|___|___|

5. Hepatitis Medical Support & Testing |___|___|___|

6. Other STI Support and Testing |___|___|___|

7. Dental Care |___|___|___|

8. Other Medical Services

(Specify) ___________________________ |___|___|___|

After Care Services Sessions

1. Continuing Care |___|___|___|

2. Relapse Prevention |___|___|___|

3. Recovery Coaching |___|___|___|

4. Self-Help and Mutual Support Groups |___|___|___|

5. Spiritual Support |___|___|___|

6. Other After Care Services

(Specify) ___________________________ |___|___|___|

Education Services Sessions

1. Substance Misuse Education |___|___|___|

2. HIV/AIDS Education |___|___|___|

3. Hepatitis Education |___|___|___|

4. Other STI Education Services |___|___|___|

5. Naloxone Training |___|___|___|

6. Fentanyl Test Strip Training |___|___|___|

7. Other Education Services

(Specify) ___________________________ |___|___|___|

Recovery Support Services Sessions

1. Peer Coaching or Mentoring |___|___|___|

2. Vocational Services |___|___|___|

3. Recovery Housing |___|___|___|

4. Recovery Planning |___|___|___|

5. Case Management Services to Specifically

Support Recovery |___|___|___|

6. Alcohol- and Drug-Free Social Activities |___|___|___|

7. Information and Referral |___|___|___|

8. Other Recovery Support Services

(Specify) _________________________ |___|___|___|

9. Other Peer-to-Peer Recovery Support

Services (Specify) ____________________ |___|___|___|

2. Has this client attended 60% or more of their planned services?

Yes No

3. Did this client receive any services via telehealth or a virtual platform?

Yes No

4. Has this client previously been diagnosed with an opioid use disorder?

Yes No [SKIP TO QUESTION 5]

4a. In the past 30 days, which FDA-approved medication did the client receive for the treatment of this opioid use disorder? [CHECK ALL THAT APPLY.]

Methadone [IF RECEIVED] Specify how many days received |___|___| Buprenorphine [IF RECEIVED] Specify how many days received |___|___| Naltrexone [IF RECEIVED] Specify how many days received |___|___| Extended‒release Naltrexone [IF RECEIVED] Specify how many doses received |___|___| Client did not receive an FDA-approved medication for a diagnosed opioid use disorder [SKIP TO QUESTION 5]

4b. Has this client taken the medication as prescribed?

No

5. Has this client previously been diagnosed with an alcohol use disorder?

Yes No [SKIP TO QUESTION 6]

5a. In the past 30 days, which FDA-approved medication did the client receive for the treatment of this alcohol use disorder? [CHECK ALL THAT APPLY.]

Naltrexone [IF RECEIVED] Specify how many days received |___|___| Extended‒release Naltrexone [IF RECEIVED] Specify how many doses received |___|___| Disulfiram [IF RECEIVED] Specify how many days received |___|___| Acamprosate [IF RECEIVED] Specify how many days received |___|___| Client did not receive an FDA-approved medication for an alcohol use disorder [SKIP TO QUESTION 6]

5b. Has this client taken the medication as prescribed?

6. Has this client previously been diagnosed with a stimulant use disorder?

Yes No [SKIP TO QUESTION 7]

6a. In the past 30 days, which interventions did the client receive for the treatment of this stimulant use disorder? [CHECK ALL THAT APPLY.]

Contingency Management [IF RECEIVED] Specify how many days received |___|___| Community Reinforcement [IF RECEIVED] Specify how many days received |___|___| Cognitive Behavioral Therapy [IF RECEIVED] Specify how many days received |___|___| Other treatment approach [IF RECEIVED] Specify how many days received |___|___| Client did not receive any intervention for a stimulant use disorder [SKIP TO QUESTION 7]

6b. Has this client attended and participated in interventions for stimulant use disorder?

Yes No

7. Has this client previously been diagnosed with a tobacco use disorder?

No [THE DISCHARGE INTERVIEW IS COMPLETE.]

7a. In the past 30 days, which FDA-approved medication did the client receive for the treatment of this tobacco use disorder? [CHECK ALL THAT APPLY.]

Nicotine Replacement [IF RECEIVED] Specify how many days received |___|___| Bupropion [IF RECEIVED] Specify how many days received |___|___| Varenicline [IF RECEIVED] Specify how many days received |___|___| Client did not receive an FDA-approved medication for a tobacco use disorder [THE DISCHARGE

INTERVIEW IS COMPLETE.]

7b. Has this client taken the medication as prescribed?

[THE DISCHARGE INTERVIEW IS COMPLETE.]

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