Voucher Program - Adult NOMs Data

B. Functioning

Survey 4; Feeling - 30 Days
4. The following questions ask about how you have been feeling during the past 30 days. For each question, please indicate how often you had this feeling.

During the past 30 days, about how often did you feel...
a. nervous? *
b. hopeless? *
c. restless or fidgety? *
d. so depressed that nothing could cheer you up? *
e. that everything was an effort? *
f. worthless? *
g. During the past 30 days how much have you been bothered by these psychological or emotional problems? *

B. Functioning

Survey 5; Feeling - 4 Weeks
5. The following questions ask about how you have been feeling during the past 4 weeks.

In the past 4 weeks...
a. how would you rate your quality of life? *
b. do you have enough energy for everyday life? *
c. how satisfied are you with your ability to perform your daily living activities? *
d. how satisfied are you with your health? *
e. how satisfied are you with yourself? *
f. how satisfied are you with your personal relationships? *

B. Functioning

Survey 6; Alcohol, Cigarettes, and Other Drugs
6. The following questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances we’ll talk about are prescribed by a doctor (like pain medications). But I will only record those if you have taken them for reasons or in doses other than prescribed.

In the past 30 days, how often have you used...
a. tobacco products (cigarettes, chewing tobacco, cigars, etc.)? *
b. alcoholic beverages (beer, wine, liquor, etc.)? *
b1. [IF B ≥ ONCE OR TWICE, AND RESPONDENT IS MALE] How many times in the past 30 days have you had five or more drinks in a day? [CLARIFY IF NEEDED: A standard alcoholic beverage (e.g., 12 oz. beer, 5 oz. wine, 1.5 oz. liquor).]
b2. [IF B ≥ ONCE OR TWICE, AND RESPONDENT IS NOT MALE] How many times in the past 30 days have you had four or more drinks in a day? [CLARIFY IF NEEDED: A standard alcoholic beverage (e.g., 12 oz. beer, 5 oz. wine, 1.5 oz. liquor).]
c. cannabis (marijuana, pot, grass, hash, etc.)? *
d. cocaine (coke, crack, etc.)? *
e. prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)? *
f. methamphetamine (speed, crystal meth, ice, etc.)? *
g. inhalants (nitrous oxide, glue, gas, paint thinner, etc.)? *
h. sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, Rohypnol, GHB, etc.)? *
i. hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)? *
j. street opioids (heroin, opium, etc.)? *
k. prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)? *
l. other - specify (e-cigarettes, etc.):

[OPTIONAL: GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCORE REPORTED BY GRANTEE STAFF AT PROJECT’S DISCRETION.]
Date GAF was Administered

Month Day Year
Date
What was the consumer's score?

E. Crime and Criminal Justice

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

Times

# of Times

I. Reassessment Status

[SECTION I IS REPORTED BY GRANTEE STAFF AT REASSESSMENT.]
1. Have you or other grant staff had contact with the consumer within 90 days of the last encounter? *

Yes No
2. Is the consumer still receiving services from you project? *

Yes No

J. Clinical Discharge Status

[SECTION J IS REPORTED BY GRANTEE STAFF ABOUT THE CONSUMER AT CLINICAL DISCHARGE.]
1. On what date was the consumer discharged? (Month and Year) *
2. What is the consumer's discharge status? *

Mutually agreed cessation of treatment Withdrew from/refused treatment No contact within 90 days of last encounter Clinically referred out Death Other (Specify)
Other (Specify)

NOMS - Adult Data Submission Form

Record Management

Behavioral Health Diagnosis

A. Demographic Information

B. Functioning

B. Functioning

B. Functioning

B. Functioning

[OPTIONAL: GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCORE REPORTED BY GRANTEE STAFF AT PROJECT’S DISCRETION.]

B. Functioning

B. Functioning

C. Stability In Housing

D. Education

E. Crime and Criminal Justice

F. Perception of Care

G. Social Connectedness

I. Reassessment Status

J. Clinical Discharge Status

K. Services Received