Attachment 8 - SUPRT-A and SUPRT-C Tool.pdf
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- Solicitation number
- 1626-009
- Issued by
- Anchorage Municipality, Alaska
About this file
This file contains the Substance Abuse and Mental Health Services Administration (SAMHSA) Unified Performance Reporting Tool (SUPRT), a comprehensive data collection instrument designed for agencies administering behavioral health services funded through SAMHSA grants. The SUPRT consists of two primary components: the SUPRT-A administrative report and the SUPRT-C client-reported outcomes forms, with versions tailored for adults, youth ages 12-17, children ages 5-17, and young children ages 0-4. The tools are designed to collect standardized data on client demographics, behavioral health history, screenings, diagnoses, services received, and recovery outcomes across baseline, reassessment, annual, and closeout assessments. Data collection occurs at program intake, 3 to 6-month reassessment intervals, annual reviews for clients in care exceeding 12 months, and upon program closeout. The SUPRT-A administrative assessment requires approximately 20 minutes to complete and captures client identification information, behavioral health history including insurance coverage and crisis events, substance use and mental health screenings, ICD-10-CM diagnoses, and detailed service delivery information including behavioral health services, crisis services, recovery support services, and integrated health services. The SUPRT-C client or caregiver-reported forms require 3 to 15 minutes depending on the age group and assessment type, focusing on demographics, social determinants of health, and client-reported core outcomes including recovery status, physical and mental health ratings, housing stability, employment, and quality of life assessments on a 0-100 scale.
The tools employ voluntary participation with no loss of services for clients or caregivers declining to respond, and all data collection adheres to the Privacy Act of 1974 with no personally identifiable information submitted to SAMHSA. Participation is protected under OMB control number 0930-0400, which expires January 31, 2028. The SUPRT instruments support comprehensive performance measurement across multiple behavioral health service domains and facilitate data submission to SAMHSA's Performance Accountability and Reporting System (SPARS). All forms have passed accessibility compliance testing including Section 508, WCAG 2.0, PDF/UA 1.0, and HHS standards, confirming tagged PDF structure, logical reading order, appropriate color contrast, and proper form field configuration. The tools are designed to collect trend and pattern data for service improvement at community and national levels while maintaining client privacy and confidentiality.
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Text version
OMB No. 0930-0400 Expires: 01/31/2028
Substance Abuse and Mental Health Services Administration (SAMHSA) Unified Performance
Reporting Tool (SUPRT) - A
Administrative Report
June 2025
Public reporting burden for this collection of information is estimated to average 20 minutes per response. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The control number for this project is 0930-0400.
Contents
A. RECORD MANAGEMENT
B. BEHAVIORAL HEALTH HISTORY
C. BEHAVIORAL HEALTH SCREENINGS
D. BEHAVIORAL HEALTH DIAGNOSIS
E. SERVICES RECEIVED
F. DEMOGRAPHICS
SAMHSA Unified Performance Reporting Tool (SUPRT) – A
A. RECORD MANAGEMENT
Client ID | | | | | | | | | |
Site ID | | | | | | | | | |
Grant ID | | | | | | | | | |
A1. [AT BASELINE] What is the client’s month and year of birth (MM/YYYY)?
A2. What is the date of the assessment (MM/DD/YYYY)?
MONTH DAY YEAR
A3. Which assessment type?
Baseline Reassessment (for clients in care at 3 or 6 months) Annual (for clients in care for more than 12 months) Record closeout
A4. [AT BASELINE ASSESSMENT ONLY] When did the client first receive services under this grant
(MM/YYYY)?
A5. [AT REASSESSMENT OR ANNUAL OR CLOSEOUT] When did the client most recently receive services under this grant (MM/YYYY)?
A6. [AT RECORD CLOSEOUT] Why are you closing out this client’s record?
Completed the program No contact Withdrew from/Refused treatment
Referred out
Transferred to a different grant program Incarceration
Moved
Death Other
A6a. [IF QUESTION A6 IS DEATH] What is the cause of death?
Suicide Overdose
Other behavioral health cause Other cause
Not documented in record
B. BEHAVIORAL HEALTH HISTORY
B1. What insurance does the client or guarantor have?
SELECT ALL THAT APPLY
□ Medicare
□ Medicaid
□ Private Insurance or Employer Provided
□ TRICARE, CHAMPUS, CHAMPVA or other veteran or military health care
□ Indian Health Service Tribal Health Care
□ An assistance program [for example, a medication assistance program]
□ Any other type of health insurance or health coverage plan None Not documented in records or not documented in records using this standard
B2. In the past 30 days, was the client admitted to a hospital?
Yes – Behavioral health reasons, for example mental health or substance use disorder Yes – other health reasons, for example injury or illness No Not documented in records or not documented in records using this standard
B3. In the past 30 days, did the client visit an emergency department?
Yes – Behavioral health reasons, for example mental health or substance use disorder Yes – other health reasons, for example injury or illness No Not documented in records or not documented in records using this standard
B4. In the past 30 days, did the client experience a behavioral health crisis or request crisis response, for example from 988 or 911?
Yes No Not documented in records or not documented in records using this standard
B4a. [IF QUESTION B4 IS YES] What is the primary crisis issue?
Suicide risk Other risk of harm to self or others (e.g. NSSI, homicidal thoughts) Mental health Substance use other than overdose Overdose Other Not documented in records or not documented in records using this standard
B5. In the past 30 days, did the client spend one or more nights at a residential behavioral health treatment facility, for example crisis stabilization or residential substance use disorder treatment facility, including for withdrawal management?
Yes No Not documented in records or not documented in records using this standard
B6. [CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, was the client arrested, taken into custody, or detained?
Yes No Not applicable Not documented in records or not documented in records using this standard
B7. [CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, did the client spend one or more nights in jail or a correctional facility?
Yes No Not applicable Not documented in records or not documented in records using this standard
B8. [CLIENTS 11 YEARS OR OLDER ONLY] In the past 90 days, has the client been on probation, parole, or intensive pretrial supervision for one or more days?
Yes No Not applicable
C. BEHAVIORAL HEALTH SCREENINGS
Please indicate the client’s screening results, as documented in an individual clinical or client record (whether paper or electronic).
C1. Within the past 30 days, was the client screened or assessed by your program for risk of suicidality?
Yes – Screening result was negative (no or low risk) Yes – Screening result was positive (at risk) No, not screened or assessed Not documented in records or not documented in records using this standard
C2. Within the past 30 days, was the client screened or assessed by your program for substance use?
Yes – Screening result was negative (no or low risk for substance use disorder (SUD)) Yes – Screening result was positive (at risk for SUD) No, not screened or assessed Not documented in records or not documented in records using this standard
C3. [IF QUESTION C2 IS “YES”] During the screening and assessment process, what was the reported use for the following substances?
Substance
Recent use (within the past
30 days)
Past use (greater than
30 days) Never used Not documented
a. Alcohol
b. Opioids
c. Cannabis
d. Sedative, hypnotic, or anxiolytics
e. Cocaine
f. Methamphetamine
g. Other stimulants
h. Hallucinogens or psychedelics
i. Inhalants
j. Other psychoactive substances
k. Tobacco or nicotine
C4. Within the past 30 days, was the client screened or assessed by your program for the following disorders? (Please select one per disorder)
Disorder Screened / assessed Not screened Not applicable
Not documented in records
a. Depression, depressive disorders
b. Anxiety disorders
c. Bipolar disorders
d. Psychosis, psychotic disorders
e. Trauma disorders, including PTSD
f. [IF CLIENT < 18 YEARS] Developmental, neurologic disorders
g. [IF CLIENT < 18 YEARS] Behavioral and emotional
D. BEHAVIORAL HEALTH DIAGNOSIS
Please indicate the client’s current behavioral health diagnoses using the most current version of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes, as made by a clinician and documented in a clinical record.
D1. Substance use disorder diagnosis (record up to 3)
Enter ICD-10-CM code F10-F19- or indicate no diagnosis | | | | |
Enter ICD-10-CM code F10-F19- or indicate no diagnosis | | | | |
Enter ICD-10-CM code F10-F19- or indicate no diagnosis | | | | | No diagnosis
D2. Mental health diagnosis (record up to 3)
Enter ICD-10-CM code F20-F99- or indicate no diagnosis | | | | |
Enter ICD-10-CM code F20-F99- or indicate no diagnosis | | | | |
Enter ICD-10-CM code F20-F99- or indicate no diagnosis | | | | | No diagnosis
D3. Other factors influencing health status (record up to 3)
Enter ICD-10-CM code Z55-Z65 or Z69-Z76- or indicate no diagnosis | | | | |
Enter ICD-10-CM code Z55-Z65 or Z69-Z76- or indicate no diagnosis | | | | |
Enter ICD-10-CM code Z55-Z65 or Z69-Z76- or indicate no diagnosis | | | | | No diagnosis
OTHER HEALTH STATUS QUESTIONS
Please indicate additional health status information as applicable and as documented in a clinical record.
D4. Is the client currently pregnant?
Yes No Not applicable Not documented in records or not documented in records using this standard
D5. [CLINICAL HIGH RISK PSYCHOSIS CLIENTS ONLY] [AT REASSESSMENT OR ANNUAL] Has the client experienced an episode of psychosis since their last assessment?
Yes No
D6. [SUBSTANCE USE DISORDER TREATMENT CLIENTS ONLY] In the previous 30 days, did the client experience an overdose or take too much of a substance that resulted in needing supervision or medical attention?
Yes No Not applicable Not documented in records or not documented in records using this standard
D6a. [IF QUESTION D6 IS YES] After taking too much of a substance or overdosing, what intervention(s) did the client receive?
SELECT ALL THAT APPLY
□ Naloxone (Narcan) or other opioid overdose reversal medication
□ Care in an emergency department
□ Care from a primary care provider
□ Admission to a hospital
□ Supervision by someone else
□ Other Not applicable Not documented in records or not documented in records using this standard
D7. [MAI PROGRAM CLIENTS ONLY] Has the client ever tested positive for HIV?
Yes, HIV-positive No, HIV-negative Not documented in records or not documented in records using this standard
D7a. [IF QUESTION D7 IS YES, HIV-INFECTED] Is the client currently on ART?
Yes, currently taking ART No, not currently taking ART Not documented in records or not documented in records using this standard
D7b. [IF QUESTION D7 IS NO, HIV-NEGATIVE] Is the client currently taking HIV PrEP?
Yes, currently on PrEP No, not currently on PrEP Not documented in records or not documented in records using this standard
D8. Has the client ever tested positive for Hepatitis C?
Yes, active or previous Hepatitis C infection No, never had Hepatitis C
D8a. [IF QUESTION D8 IS YES, ACTIVE OR PREVIOUS HEPATITIS C INFECTION] Is the client currently taking viral Hepatitis C treatment?
Yes, currently taking viral Hepatitis C treatment No, took treatment and cured No, Hepatitis C infection naturally cleared without need for treatment No, not currently taking treatment
E. SERVICES RECEIVED
Services Received is collected by grantee staff at Reassessment, Annual Assessments and Closeout.
Identify all the services your grant project provided to the client since their previous assessment.
BEHAVIORAL HEALTH SERVICES
E1. Since the previous administrative assessment, did the project provide or refer the client for one or more behavioral health services?
Yes No Not documented in records
E1a-p. If yes, please indicate which:
Yes – provided
Referred for service
No – not provided or referred
Not documented in records / unknown
a. Case or care management or coordination
b. Person- or family-centered treatment planning
c. Substance use psychoeducation
d. Mental health psychoeducation
e. Mental health therapy
f. Co-occurring therapy (substance use & mental health)
g. Group counseling
h. Individual counseling
i. Family counseling
j. Psychiatric rehabilitation services
k. Prescription medication for mental health disorder
l. Medication for substance use disorder
m. Intensive day treatment
n. Withdrawal management (whether in hospital, residential, or ambulatory)
o. After care planning and referrals
p. Co-occurring disorders (including developmental or neurologic)
E2a-j. [IF E1a_l = MEDICATION FOR SUBSTANCE USE DISORDER IS YES – PROVIDED] Indicate medication received
Yes – received No – not received
Not documented in records / unknown
a. Naltrexone
b. Extended-release Naltrexone
c. Disulfiram
d. Acamprosate
e. Methadone
f. Buprenorphine
g. Nicotine cessation therapy (e.g. Nicotine patch, gum, lozenge) ..
h. Bupropion
i. Varenicline
j. Other
CRISIS SERVICES
E3. Since the previous administrative assessment, did the project provide or refer the client for one or more crisis services?
Yes No Not documented in records
E3a-d. If yes, please indicate which:
Yes – provided Referred for service
No – not provided or referred
Not documented in records / unknown
a. Crisis response planning
b. Crisis response
c. Crisis stabilization
d. Crisis follow-up
RECOVERY AND SUPPORT SERVICES
E4. Since the previous administrative assessment, did the project provide or refer the client for one or more recovery support services?
Yes No Not documented in records
E4a-l. If yes, please indicate which:
Yes – provided Referred for service
No – not provided or referred
Not documented in records / unknown
a. Employment support
b. Family support services, including family peer support
c. Childcare
d. Transportation
e. Education support
f. Housing support
g. Recovery housing
h. Spiritual, ceremonial, and/or traditional activities
i. Mutual support groups
j. Peer support specialist services, coaching or mentoring
k. Respite care
l. Therapeutic foster care
INTEGRATED SERVICES
E5. Since the previous administrative assessment, did the project provide or refer the client for one or more integrated services?
Yes No Not documented in records
E5a-i. If yes, please indicate which:
Yes – provided Referred for service
No – not provided or referred
Not documented in records / unknown
a. Primary health care
b. Maternal health care or OB/GYN
c. HIV testing
d. Viral hepatitis testing
e. HIV treatment
f. HIV pre-exposure prophylaxis (PrEP)
g. Viral hepatitis treatment
h. Other STI testing or treatment
i. Dental care
F. DEMOGRAPHICS
Demographics is collected by grantee staff at Baseline only if the Client or Caregiver declined consent for the SUPRT-C.
If the individual declined the Client or Caregiver SUPT-C form at baseline, please provide demographic information below. These data can be pulled from other internal sources, however it should still come directly from clients, with the exact categories or response options as indicated below, and not be assumed.
F1. What is the client’s race or ethnicity? Select all that apply and enter additional details in the spaces below.
□ White – Provide details below.
□ German
□ Irish
□ English
□ Italian
□ Polish
□ French
□ Enter, for example, Scottish, Norwegian, Dutch, etc. ________________________________
□ Hispanic or Latino – Provide details below.
□ Mexican or Mexican American
□ Puerto Rican
□ Cuban
□ Salvadoran
□ Dominican
□ Colombian
□ Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. _________________________
□ Black or African American – Provide details below.
□ African American
□ Jamaican
□ Haitian
□ Nigerian
□ Ethiopian
□ Somali
□ Enter, for example, Ghanaian, South African, Barbadian, etc. ________________________
□ Asian – Provide details below.
□ Chinese
□ Filipino
□ Asian Indian
□ Vietnamese
□ Korean
□ Japanese
□ Enter, for example, Pakistani, Cambodian, Hmong, etc. _____________________________
□ American Indian or Alaska Native – Provide details below.
□ Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Tlingit, etc. __________________________________________
□ Middle Eastern or North African – Provide details below.
□ Lebanese
□ Iranian
□ Egyptian
□ Syrian
□ Moroccan
□ Israeli
□ Enter, for example, Algerian, Iraqi, Kurdish, etc. ___________________________________
□ Native Hawaiian or Pacific Islander – Provide details below.
□ Native Hawaiian
□ Samoan
□ Chamorro
□ Tongan
□ Fijian
□ Marshallese
□ Enter, for example, Palauan, Tahitian, Chuukese, etc. ______________________________ Race/ethnicity not captured in grantee records using detailed OMB categories.
Client/caregiver declined to provide race/ethnicity.
F2. What is the individual’s sex?
Female Male
Substance Abuse and Mental Health Services Administration (SAMHSA) Unified Performance
Reporting Tool (SUPRT) - C
ADULT / CLIENT / ANNUAL FORM
Version: June 2025
SAMHSA Unified Performance Reporting Tool (SUPRT) - C Age: ADULT (18+) Respondent: CLIENT Assessment: ANNUAL
Expires: 01/31/2028
CLIENT CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for adults (persons 18 years or older) responding for themselves. If that’s not you, please ask your provider for the form for Caregivers/family members or for youth (12-17 years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your provider.
How is my information used?
SAMHSA does not collect your name or information that can identify you. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data.
SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
• skip questions you do not want to answer.
• stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 7 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.
Public reporting burden for this collection of information is estimated to average 7 minutes per response. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB)
A. CLIENT-REPORTED CORE OUTCOMES
A1. Please choose the option that best applies to you right now:
I consider myself to be in recovery from substance use issues I consider myself to be in recovery from mental health issues I consider myself to be in recovery from substance use and mental health issues I do not consider myself to be in recovery for substance use or mental health issues I prefer not to answer
A2. As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below.
Strongly
Agree Agree Somewhat
Agree Somewhat Disagree Disagree
Strongly Disagree
Prefer not to answer
a. I am physically fine most days
b. My mental health is fine most days
c. My substance use does not cause problems in my life
d. I have stable housing
e. I have a steady job or am involved in things like school, training, or volunteering
f. My life has purpose and meaning
g. I have enough money to meet my needs
h. I am proud of the community I live in and feel a part of it
i. I am supported by the people around me
j. The future appears bright to me.
k. I am in control of my life
l. I bounce back quickly after hard times
A3. On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life?
A4. As a result of the services you received, which goals did you make progress on?
CHECK ALL THAT APPLY
□ Improve the symptoms that led me to services (for example distress, anxiety)
□ Reduce my drug and/or alcohol use
□ Gain access to medical services I need
□ Enroll in or finish education (for example GED, degree, vocational training)
□ Get or maintain a job
□ Live in stable housing
□ Be a better parent or caregiver
□ Improve my friendships and relationships
□ Comply with court order or avoid contact with the police and/or justice system
□ Other goal - Please describe: ____________________________________________________ Prefer not to answer
Thank you for completing this annual assessment form.
Public reporting burden for this collection of information is estimated to average 7 minutes per response. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The control number for this project is 0930-0400.
[OFFICE USE ONLY] RECORD MANAGEMENT – ADULT / CLIENT / ANNUAL
CLIENT ID | | | | | | | | | | | |
SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | |
1. Was this assessment conducted with the client/caregiver?
Yes – Client Yes – Caregiver/Proxy No
1a. [IF QUESTION 1 IS YES] When?
| | | / | | | / | | | | | MM / DD / YYYY
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
Client/Caregiver was unable to provide consent Client was not reached for assessment Client no longer in care
Substance Abuse and Mental Health Services Administration (SAMHSA) Unified Performance
Reporting Tool (SUPRT) - C
ADULT / CLIENT / BASELINE FORM
SAMHSA Unified Performance Reporting Tool (SUPRT) – C Age: ADULT (18+) Respondent: CLIENT Assessment: BASELINE
Expires: 01/31/2028
CLIENT CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for adults (persons 18 years or older) responding for themselves. If that’s not you, please ask your provider for the form for caregivers/family members or for youth (12-17 years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your provider.
How is my information used?
SAMHSA does not collect your name or information that can identify you. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data.
SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
• skip questions you do not want to answer.
• stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 15 minutes.
Public reporting burden for this collection of information is estimated to average 15 minutes per response. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB)
A. DEMOGRAPHICS
A1. What is your race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.
□ White – Provide details below.
□ German
□ Irish
□ English
□ Italian
□ Polish
□ French
□ Enter, for example, Scottish, Norwegian, Dutch, etc. _______________________________
□ Hispanic or Latino – Provide details below.
□ Mexican or Mexican American
□ Puerto Rican
□ Cuban
□ Salvadoran
□ Dominican
□ Colombian
□ Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. _________________________
□ Black or African American – Provide details below.
□ African American
□ Jamaican
□ Haitian
□ Nigerian
□ Ethiopian
□ Somali
□ Enter, for example, Ghanaian, South African, Barbadian, etc. ________________________
□ Asian – Provide details below.
□ Chinese
□ Filipino
□ Asian Indian
□ Vietnamese
□ Korean
□ Japanese
□ Enter, for example, Pakistani, Cambodian, Hmong, etc. _____________________________
□ American Indian or Alaska Native – Provide details below.
□ Specify, for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Tlingit, etc. _________________________________________
□ Middle Eastern or North African – Provide details below.
□ Lebanese
□ Iranian
□ Egyptian
□ Syrian
□ Moroccan
□ Israeli
□ Enter, for example, Algerian, Iraqi, Kurdish, etc. ___________________________________
□ Native Hawaiian or Pacific Islander – Provide details below.
□ Native Hawaiian
□ Samoan
□ Chamorro
□ Tongan
□ Fijian
□ Marshallese
□ Enter, for example, Palauan, Tahitian, Chuukese etc. ______________________________
A2. What is your sex?
Female Male
A3. Do you speak a language other than English at home? (If no, please skip to question A4.)
Yes No Prefer not to answer
A3a. For persons speaking a language other than English (answering yes to the question above): What is this language(s)?
CHECK ALL THAT APPLY
□ American Sign Language (ASL)
□ Arabic
□ Chinese
□ French
□ Portuguese
□ Spanish
□ Other Language – specify: ________________________________________________ Prefer not to answer
A4. Have you ever served in the Armed Forces, the Reserves, the National Guard or other Uniformed Services?
Yes, currently serving Yes, served in the past No Prefer not to answer
A5. Please respond to the following questions about your physical health.
Yes No Prefer not to answer
a. Are you deaf or do you have serious difficulty hearing?
b. Are you blind or do you have serious difficulty seeing, even when wearing glasses?
c. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
d. Do you have serious difficulty walking or climbing stairs?
e. Do you have difficulty dressing or bathing?
f. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
B. SOCIAL DRIVERS OF HEALTH
B1. How hard is it for you to pay for the very basics like food, housing, medical care, and heating?
Very hard Somewhat hard Not hard at all Prefer not to answer
B2. What is your living situation today?
I have a steady place to live I have a place to live today but I am worried about losing it in the future I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) Prefer not to answer
B3. Which of the following best describes your current living situation?
House or apartment Your partner’s place A friend or relative’s and paying rent A friend or relative’s and not paying rent Permanent housing program Transitional housing program Domestic violence shelter Emergency shelter Voucher hotel or motel Hotel or motel you pay for Residential drug or alcohol program Jail or prison Car or other vehicle Abandoned building Anywhere outside
Somewhere else [where]: _______________________________________________________ Prefer not to answer
B4. Are you currently employed?
Employed, full time or part time (includes temporary, seasonal, hours change each week) Not employed, seeking employment Not employed, not seeking employment (includes if you are in school and not seeking a job, retired, not looking for work because of a disability, a homemaker, etc.)
Other – specify: _______________________________________________________________
B5. What is the highest level of education you have finished?
Less than high school diploma High school degree or GED Some vocational, technical, college, or university credit(s) Associate's degree or technical/vocational certificate 4-year degree or higher Prefer not to answer
B6. In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?
Enrolled, attending regularly Enrolled, not attending regularly Not enrolled Prefer not to answer
B7. In the last 3 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?
CHECK ALL THAT APPLY
□ Yes, it has kept me from medical appointments or from getting my medications
□ Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
□ No
C. CLIENT-REPORTED CORE OUTCOMES
C1. Please choose the option that best applies to you right now:
I consider myself to be in recovery from substance use issues I consider myself to be in recovery from mental health issues I consider myself to be in recovery from substance use and mental health issues I do not consider myself to be in recovery for substance use or mental health issues I prefer not to answer
C2. As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below.
Strongly
Agree Agree Somewhat
Agree Somewhat Disagree Disagree
Strongly Disagree
Prefer not to answer
a. I am physically fine most days
b. My mental health is fine most days
c. My substance use does not cause problems in my life
d. I have stable housing
e. I have a steady job or am
g. I have enough money to meet my needs
h. I am proud of the community I live in and feel a part of it
i. I am supported by the people around me
j. The future appears bright to me.
k. I am in control of my life
C3. On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life?
C4. Which goals do you have for participating in this program?
CHECK ALL THAT APPLY
□ Improve the symptoms that led me to services (for example distress, anxiety)
□ Reduce my drug and/or alcohol use
□ Gain access to medical services I need
□ Enroll in or finish education (for example GED, degree, vocational training)
□ Get or maintain a job
□ Live in stable housing
□ Be a better parent or caregiver
□ Improve my friendships and relationships
□ Comply with court order or avoid contact with the police and/or justice system
□ Other goal - please describe: _____________________________________________________ Prefer not to answer
Thank you for completing this baseline form.
Public reporting burden for this collection of information is estimated to average 15 minutes per response. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The control number for this project is 0930-0400.
[OFFICE USE ONLY] RECORD MANAGEMENT – ADULT / CLIENT / BASELINE
CLIENT ID | | | | | | | | | | | |
SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | |
1. Was this assessment conducted with the client/caregiver?
Yes – Client Yes – Caregiver/Proxy No
1a. [IF QUESTION 1 IS YES] When?
| | | / | | | / | | | | | MM / DD / YYYY
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
Client/Caregiver was unable to provide consent
Substance Abuse and Mental Health Services Administration (SAMHSA) Unified Performance
Reporting Tool (SUPRT) - C
ADULT / CLIENT / REASSESSMENT FORM
Age: ADULT (18+) Respondent: CLIENT Assessment: REASSESSMENT
Expires: 01/31/2028
CLIENT CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for adults (persons 18 years or older) responding for themselves. If that’s not you, please ask your provider for the form for Caregivers/family members or for youth (12-17 years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your provider.
How is my information used?
SAMHSA does not collect your name or information that can identify you. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data.
SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
• skip questions you do not want to answer.
• stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 10 minutes.
Public reporting burden for this collection of information is estimated to average 10 minutes per response. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB)
A. SOCIAL DRIVERS OF HEALTH
A1. How hard is it for you to pay for the very basics like food, housing, medical care, and heating?
Very hard Somewhat hard Not hard at all Prefer not to answer
A2. What is your living situation today?
I have a steady place to live I have a place to live today but I am worried about losing it in the future I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) Prefer not to answer
A3. Which of the following best describes your current living situation?
House or apartment Your partner’s place A friend or relative’s and paying rent A friend or relative’s and not paying rent Permanent housing program Transitional housing program Domestic violence shelter Emergency shelter Voucher hotel or motel Hotel or motel you pay for Residential drug or alcohol program Jail or prison Car or other vehicle Abandoned building Anywhere outside
Somewhere else [where]: _______________________________________________________ Prefer not to answer
A4. Are you currently employed?
Employed, full time or part time (includes temporary, seasonal, hours change each week) Not employed, seeking employment Not employed, not seeking employment (includes in school not seeking, retired, due to disability, homemaker, etc.)
Other – specify: _______________________________________________________________
A5. What is the highest level of education you have finished?
Less than high school diploma High school degree or GED Some vocational, technical, college, or university credit(s) Associate's degree or technical/vocational Certificate 4-year degree or higher Prefer not to answer
A6. In the last 3 months, have you attended school/college, homeschool, or vocational training regularly?
Enrolled, attending regularly Enrolled, not attending regularly Not enrolled Prefer not to answer
A7. In the last 3 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?
CHECK ALL THAT APPLY
□ Yes, it has kept me from medical appointments or from getting my medications.
□ Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need.
□ No
B. CLIENT-REPORTED CORE OUTCOMES
B1. Please choose the option that best applies to you right now:
I consider myself to be in recovery from substance use issues I consider myself to be in recovery from mental health issues I consider myself to be in recovery from substance use and mental health issues I do not consider myself to be in recovery for substance use or mental health issues I prefer not to answer
B2. As of right now, please select whether you strongly agree, agree, somewhat agree, somewhat disagree, disagree, or strongly disagree with each statement in the table below.
Strongly Agree Agree
Somewhat Agree
Somewhat Disagree Disagree
Strongly Disagree
Prefer not to answer
a. I am physically fine most days
b. My mental health is fine most days
c. My substance use does not cause problems in my life
d. I have stable housing
e. I have a steady job or am
g. I have enough money to meet my needs
h. I am proud of the community I live in and feel a part of it
i. I am supported by the people around me
j. The future appears bright to me.
k. I am in control of my life
B3. On a scale of 0 to 100, if 0 represents no quality of life and 100 is perfect quality of life, how would you rate your quality of life?
B4. As a result of the services you received, which goals did you make progress on?
CHECK ALL THAT APPLY
□ Improve the symptoms that led me to services (for example distress, anxiety)
□ Reduce my drug and/or alcohol use
□ Gain access to medical services I need
□ Enroll in or finish education (for example GED, degree, vocational training)
□ Get or maintain a job
□ Live in stable housing
□ Be a better parent or caregiver
□ Improve my friendships and relationships
□ Comply with court order or avoid contact with the police and/or justice system
□ Other goal - Please describe: ____________________________________________________ Prefer not to answer
Thank you for completing this reassessment form.
Public reporting burden for this collection of information is estimated to average 10 minutes per response. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The control number for this project is 0930-0400.
[OFFICE USE ONLY] RECORD MANAGEMENT – ADULT / CLIENT / REASSESSMENT
CLIENT ID | | | | | | | | | | | |
SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | |
1. Was this assessment conducted with the client/caregiver?
Yes – Client Yes – Caregiver/Proxy No
1a. [IF QUESTION 1 IS YES] When?
| | | / | | | / | | | | | MM / DD / YYYY
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
Client/Caregiver was unable to provide consent
Substance Abuse and Mental Health Services Administration (SAMHSA) Unified Performance
Reporting Tool (SUPRT) - C
CHILD (5 TO 17) / CAREGIVER / BASELINE FORM
Age: CHILD (5 to 17) Respondent: CAREGIVER Assessment: BASELINE
Expires: 01/31/2028
CAREGIVER/FAMILY MEMBER CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for caregivers or family members responding for their child. If that’s not you, please ask your provider for the form for Youth (12 to 17) responding for themselves or for adults (18+ years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your child’s behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your child’s provider.
How is my information used?
SAMHSA does not collect your child’s name or information that can identify your child. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data.
SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
• skip questions you do not want to answer.
• stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 10 minutes.
Public reporting burden for this collection of information is estimated to average 10 minutes per response. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB)
A1. What is your child’s race or ethnicity? Select all that apply and enter additional details in the spaces below. Note, you may report more than one group.
□ White – Provide details below.
□ German
□ Irish
□ English
□ Italian
□ Polish
□ French
□ Enter, for example, Scottish, Norwegian, Dutch, etc. _______________________________
□ Hispanic or Latino – Provide details below.
□ Mexican or Mexican American
□ Puerto Rican
□ Cuban
□ Salvadoran
□ Dominican
□ Colombian
□ Enter, for example, Guatemalan, Spaniard, Ecuadorian, etc. _________________________
□ Black or African American – Provide details below.
□ African American
□ Jamaican
□ Haitian
□ Nigerian
□ Ethiopian
□ Somali
□ Enter, for example, Ghanaian, South African, Barbadian, etc. ________________________
□ Asian – Provide details below.
□ Chinese
□ Filipino
□ Asian Indian
□ Vietnamese
□ Korean
□ Japanese
□ Enter, for example, Pakistani, Cambodian, Hmong, etc. _____________________________
□ American Indian or Alaska Native – Provide details below.
□ Lebanese
□ Iranian
□ Egyptian
□ Syrian
□ Moroccan
□ Israeli
□ Enter, for example, Algerian, Iraqi, Kurdish, etc. ___________________________________
□ Native Hawaiian or Pacific Islander – Provide details below.
□ Native Hawaiian
□ Samoan
□ Chamorro
□ Tongan
□ Fijian
□ Marshallese
□ Enter, for example, Palauan, Tahitian, Chuukese etc. ______________________________
A2. What is your child’s sex?
Female Male
A3. Does your child speak a language other than English at home? (If no, please skip to question A4.)
Yes No Prefer not to answer
A3a. For persons speaking a language other than English (answering yes to the question above): What is this language(s)?
CHECK ALL THAT APPLY
□ American Sign Language (ASL)
□ Arabic
□ Chinese
□ French
□ Portuguese
□ Spanish
□ Other Language – specify: ________________________________________________
A4. Please respond to the following questions about your child’s physical health.
Yes No Prefer not to answer
a. Is your child deaf or does your child have serious difficulty hearing?
b. Is your child blind or does your child have serious difficulty seeing, even when wearing glasses?
c. Because of a physical, mental, or emotional condition, does your child have serious difficulty concentrating, remembering, or making decisions?
d. Does your child have serious difficulty walking or climbing stairs?
e. Does your child have difficulty dressing or bathing?
f. Because of a physical, mental, or emotional condition, does your child have difficulty doing errands alone such as visiting a doctor’s office or shopping?
B. SOCIAL-DRIVERS OF HEALTH
B1. How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?
Very hard Somewhat hard Not hard at all I am not the person responsible for paying for the basics for my child Prefer not to answer
B2. What is your child’s living situation today?
My child has a steady place to live My child has a place to live today but I am worried they may lose it in the future My child does not have a steady place to live (My child is temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)
Prefer not to answer
B3. Which of the following best describes your child’s current living situation?
Your house or apartment Your partner’s place A friend or relative’s and paying rent A friend or relative’s and not paying rent Permanent housing program Transitional housing program Domestic violence shelter Emergency shelter Voucher hotel or motel Hotel or motel you pay for Residential drug or alcohol program Jail or prison Car or other vehicle Abandoned building Anywhere outside Somewhere else [where]: _______________________________________________________ Prefer not to answer
B4. What is the highest level of education your child has finished?
Preschool – Kindergarten Grade 1 – Grade 5 Grade 6 – Grade 8 Grade 9 - 12 High school degree or GED
B5. In the last 3 months, has your child attended school/college, homeschool, or vocational training regularly?
Enrolled, attending regularly Enrolled, not attending regularly Not enrolled Prefer not to answer
Thank you for completing this baseline form.
Public reporting burden for this collection of information is estimated to average 10 minutes per response at baseline. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The control number for this project is 0930-0400.
[OFFICE USE ONLY] RECORD MANAGEMENT – CHILD / CAREGIVER / BASELINE
CLIENT ID | | | | | | | | | | | |
SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | |
1. Was this assessment conducted with the client/caregiver?
Yes – Client Yes – Caregiver/Proxy No
1a. [IF QUESTION 1 IS YES] When?
| | | / | | | / | | | | | MM / DD / YYYY
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
Client/Caregiver was unable to provide consent
Substance Abuse and Mental Health Services Administration (SAMHSA) Unified Performance
Reporting Tool (SUPRT) - C
CHILD (5 TO 17) / CAREGIVER / REASSESSMENT FORM
Age: CHILD (5 to 17) Respondent: CAREGIVER Assessment: REASSESSMENT
Expires: 01/31/2028
CAREGIVER/FAMILY MEMBER CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for caregivers or family members responding for their child. If that’s not you, please ask your provider for the form for Youth (12 to 17) responding for themselves or for adults (18+ years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your child’s behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your child’s provider.
How is my information used?
SAMHSA does not collect your child’s name or information that can identify your child. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data.
SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits.
If you choose to participate, you may:
• skip questions you do not want to answer.
• stop filling in the form at any time.
How long does it take to fill in the form?
It should take you about 5 minutes.
Public reporting burden for this collection of information is estimated to average 5 minutes per response. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB)
A1. How hard is it for you to pay for the very basics like food, housing, medical care, and heating for your child?
Very hard Somewhat hard Not hard at all I am not the person responsible for paying for the basics for my child Prefer not to answer
A2. What is your child’s living situation today?
My child has a steady place to live My child has a place to live today but I am worried they may lose it in the future My child does not have a steady place to live (My child is temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)
Prefer not to answer
A3. Which of the following best describes your child’s current living situation?
Your house or apartment Your partner’s place A friend or relative’s and paying rent A friend or relative’s and not paying rent Permanent housing program Transitional housing program Domestic violence shelter Emergency shelter Voucher hotel or motel Hotel or motel you pay for Residential drug or alcohol program Jail or prison Car or other vehicle Abandoned building Anywhere outside
Somewhere else [where]: _______________________________________________________
A4. What is the highest level of education your child has finished?
Preschool – Kindergarten Grade 1 – Grade 5 Grade 6 – Grade 8 Grade 9 - 12 High school degree or GED Prefer not to answer
A5. In the last 3 months, has your child attended school/college, homeschool, or vocational training regularly?
Enrolled, attending regularly Enrolled, not attending regularly Not enrolled Prefer not to answer
Thank you for completing this reassessment form.
Public reporting burden for this collection of information is estimated to average 5 minutes per response. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The control number for this project is 0930-0400.
[OFFICE USE ONLY] RECORD MANAGEMENT – CHILD / CAREGIVER / BASELINE
CLIENT ID | | | | | | | | | | | |
SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | |
1. Was this assessment conducted with the client/caregiver?
Yes – Client Yes – Caregiver/Proxy No
1a. [IF QUESTION 1 IS YES] When?
| | | / | | | / | | | | | MM / DD / YYYY
1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason.
Client/Caregiver was unable to provide consent
Substance Abuse…
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