• A. RECORD MANAGEMENT

  • Interview Type [CIRCLE ONLY ONE TYPE.]

    Intake [GO TO INTERVIEW DATE.]

  • 3-month follow-up [FOR SELECT PROGRAMS]:

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  • A. BEHAVIORAL HEALTH DIAGNOSES

    [REPORTED BY PROGRAM STAFF.]

  • Please indicate the client’s current behavioral health diagnoses using the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes listed below. Please note that some substance use disorder ICD-10-CM codes have been crosswalked to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), descriptors. Select up to three diagnoses. For each diagnosis selected, please indicate whether it is primary, secondary, or tertiary, if known. Only one diagnosis can be primary, only one can be secondary, and only one can be tertiary.

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  • A. BEHAVIORAL HEALTH DIAGNOSES (CONTINUED)

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  • A. BEHAVIORAL HEALTH DIAGNOSES (CONTINUED)

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  • A. BEHAVIORAL HEALTH DIAGNOSES (CONTINUED)

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  • A. BEHAVIORAL HEALTH DIAGNOSES (CONTINUED)

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

  • [SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT (SBIRT) GRANTS CONTINUE. ALL OTHERS GO TO SECTION A,“PLANNED SERVICES.”]

  • BEHAVIORAL HEALTH DIAGNOSES(CONTINUED)

    THIS SECTION FOR SBIRT GRANTS ONLY [ITEMS 4, 4a, AND5REPORTED ONLY AT INTAKE/BASELINE].

  • 4a. What was his/her screening score?

  • PLANNED SERVICES

    [REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT INTAKE/BASELINE.]
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  • A. DEMOGRAPHICS

    [ASKED ONLY AT INTAKE/BASELINE.]
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  •  - -

  • [*THE SYSTEM WILL ONLY SAVE MONTH AND YEAR TO MAINTAIN CONFIDENTIALITY, DAY IS NOT SAVED.]

     

     

  • A. MILITARY FAMILY AND DEPLOYMENT

  • [IF NO, REFUSED, OR DON’T KNOW, SKIP TO QUESTION A6.]

  • [SBIRT GRANTEES: FOR CLIENTS WHO SCREENED NEGATIVE, THE INTAKE INTERVIEW IS NOW COMPLETE.]

  • A. MILITARY FAMILY AND DEPLOYMENT (CONTINUED)

  • [IF NO, REFUSED, OR DON’T KNOW, SKIP TO SECTION B.]

  • [IF YES, ANSWER FOR UP TO 6 PEOPLE.] What is the relationship of that person (Service Member) to you?
    [WRITE RELATIONSHIP IN COLUMN HEADING.]

    1 = Mother 5 = Spouse
    2 = Father 6 = Partner
    3 = Brother 7 = Child
    4 = Sister 8 = Other (Specify)
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  • B. DRUG AND ALCOHOL USE

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  • Route of Administration Types:
    1. Oral 2. Nasal 3. Smoking 4. Non-intravenous (IV) injection 5. IV
    *NOTE THE USUAL ROUTE. FOR MORE THAN ONE ROUTE,
    CHOOSE THE MOST SEVERE. THE ROUTES ARE LISTED FROM
    LEAST SEVERE (1) TO MOST SEVERE (5).

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  • B. DRUG AND ALCOHOL USE (CONTINUED)

  • Route of Administration Types:
    1. Oral 2. Nasal 3. Smoking 4. Non-intravenous (IV) injection 5. IV
    *NOTE THE USUAL ROUTE. FOR MORE THAN ONE ROUTE,
    CHOOSE THE MOST SEVERE. THE ROUTES ARE LISTED FROM
    LEAST SEVERE (1) TO MOST SEVERE (5).

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  • [IF NO, REFUSED, OR DON’T KNOW, SKIP TO SECTION C.]

  • C. FAMILY AND LIVING CONDITIONS

  • C. FAMILY AND LIVING CONDITIONS (CONTINUED)

  • [IF NO, REFUSED, OR DON’T KNOW, SKIP TO SECTION D.]

  • [IF NO, REFUSED, OR DON’T KNOW, SKIP TO SECTION C7d.]

  • D. EDUCATION, EMPLOYMENT, AND INCOME

  • D. EDUCATION, EMPLOYMENT, AND INCOME (CONTINUED)

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  • E. CRIME AND CRIMINAL JUSTICE STATUS

  • [IF NO ARRESTS, SKIP TO ITEM E3.]

  • F. MENTAL AND PHYSICAL HEALTH PROBLEMS ANDTREATMENT/RECOVERY

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

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  • F. MENTAL AND PHYSICAL HEALTH PROBLEMS ANDTREATMENT/RECOVERY (CONTINUED)

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  • F. MENTAL AND PHYSICAL HEALTH PROBLEMS ANDTREATMENT/RECOVERY (CONTINUED)

  • F. MENTAL AND PHYSICAL HEALTH PROBLEMS ANDTREATMENT/RECOVERY (CONTINUED)

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  • [IF CLIENT REPORTS ZERO DAYS, RF, OR DK TO ALL ITEMS IN QUESTION F10, SKIP TO ITEM F12.]

  • F. VIOLENCE AND TRAUMA

  • [IF NO, REFUSED, OR DON’T KNOW, SKIP TO ITEM F13.]

    Did any of these experiences feel so frightening, horrible, or upsetting that, in the past and/or the present, you:

  • F. VIOLENCE AND TRAUMA (CONTINUED)

  • G. SOCIAL CONNECTEDNESS

  • H. PROGRAM-SPECIFIC QUESTIONS

    YOU ARE NOT RESPONSIBLE FOR COLLECTING DATA ON ALL SECTION H QUESTIONS. YOUR GOVERNMENT PROJECT OFFICER (GPO) HAS PROVIDED 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.]

  • H2. PROGRAM-SPECIFIC QUESTIONS

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

  • 1. Did the help you obtain any of the following benefits? [CHECK ALL THAT APPLY.]

       
                
       

       
       
       
       

  • H3. PROGRAM-SPECIFIC QUESTIONS

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

  • H5. 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:

  • H6. PROGRAM-SPECIFIC QUESTIONS

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

  • [IF FOLLOW-UP OR DISCHARGE INTERVIEW, SKIP TO H3.]

     

    [QUESTION 2 SHOULD BE REPORTED BY GRANTEE STAFF ONLY AT INTAKE/BASELINE.]

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  • [QUESTION 3 SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE, BASELINE, FOLLOW-UP, AND DISCHARGE.]

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  • H7. PROGRAM-SPECIFIC QUESTIONS

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

  • 1. Did the program provide the following?

  • H7. PROGRAM-SPECIFIC QUESTIONS (CONTINUED)

  • H8. PROGRAM-SPECIFIC QUESTIONS

    [QUESTIONS 1 AND 2 SHOULD BE ANSWERED BY THE CLIENT AT FOLLOW-UP AND DISCHARGE.]
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  • H9. 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:

  • H10. PROGRAM-SPECIFIC QUESTIONS

    [QUESTIONS 1 AND 1a SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOWUP, AND DISCHARGE. QUESTION 1b SHOULD BE REPORTED BY GRANTEE STAFF AT FOLLOWUP/DISCHARGE IF THE CLIENT HAS BEEN REFERRED FOR SERVICES.]

  • [QUESTIONS 2 AND 2a SHOULD BE REPORTED BY GRANTEE STAFF AT INTAKE/BASELINE, FOLLOWUP, AND DISCHARGE. QUESTION 2b SHOULD BE REPORTED BY GRANTEE STAFF AT FOLLOWUP/DISCHARGE IF THE CLIENT HAS BEEN REFERRED FOR SERVICES.]

  • [IF THIS IS AT INTAKE/BASELINE AND THE RESPONSE IS NEGATIVE, NOT SCREENED, OR DON’T KNOW, SECTION H IS DONE. IF THIS IS AT FOLLOW-UP OR DISCHARGE AND THE RESPONSE IS NEGATIVE, NOT SCREENED, OR DON’T KNOW, SKIP TO QUESTION 3.]

  • [IF THIS IS AT INTAKE/BASELINE, SECTION H IS DONE. IF THIS IS AT FOLLOW-UP OR DISCHARGE AND THE RESPONSE IS NO OR DON’T KNOW, SKIP TO QUESTION 3.]

  • H10. PROGRAM-SPECIFIC QUESTIONS (CONTINUED)

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

  • I. FOLLOW-UP STATUS

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

  • [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.]
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  • J. DISCHARGE STATUS (CONTINUED)

  • K. SERVICES RECEIVED

    [REPORTED BY PROGRAM STAFF ABOUT CLIENT ONLY AT DISCHARGE.]
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  • Identify the number of SESSIONS provided to the client during the client’s course of treatment/recovery. [ENTER ZERO IF NO SERVICES PROVIDED.]

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  • Should be Empty: