INTAKE GPRA SOR INFO
Which organization administered the GPRA?
Northwest Instituto Latino Addicciones
Did this client sign an evaluation consent form?
*
Yes, signed (agreed to participate in evaluation)
No,did not sign (did not agree to participate in evaluation)
If RMC Research needs to reach you (the interviewer) with questions about the GPRA, what is your email?
GPRA Initial Assessment
A. RECORD MANAGEMENT
Client ID
Client Type:
Treatment client
Client in recovery
Interview Date
-
Month
-
Day
Year
Date
Contract/Grant ID
A. Planned Services
Identify the services you plan to provide to the client during the client’s course of treatment/recovery. [SELECT “YES” OR “NO” FOR EACH ONE.] Modality
Yes
No
1.Case Management
2. Day Treatment
3. Impatient/Hospital (Other Than Detox)
4. Outpatient
5. *Outreach*
6. Intensive Outpatient
7. Methadone
8. Residential/Rehabilitation
9. Detoxification (select only one)
9. A. Hospital Impatient
9. B. Free-Standing Residential
9. C. Ambulatory Detoxification
10. After Care
11. *Recovery Support*
12. Other (Specify)
[SELECT AT LEAST ONE SERVICE.] Treatment Services [SBIRT GRANTS: YOU MUST SELECT “YES” FOR AT LEAST ONE OF THE TREATMENT SERVICES NUMBERED 1–4.]
Yes
No
1.Screening
2. Brief Intervention
3. Brief Treatment
4. Referral to Treatment
5.Assessment
6. Treatment/Recovery Planning
7. Individual Counseling
8. Group Counseling
9. Family/Marriage Counseling
10. Co-Occurring Treatment/Recovery Services
11. Pharmacological Interventions
12. HIV/AIDS Counseling
13. Other Clinical Services (Specify)
Case Management Services
Yes
No
1. Family Services (Including Marriage Education, Parenting, Child Development Services)
2. Child Care
3. Employment Services
3. A. Pre-Employment
3. B. Employment Coaching
4. Individual Services Coordination
5. *Transportation*
6. HIV/AIDS Service
7. Supportive Transitional Drug-Free Housing Services
8. Other Case Management Services (Specify)
Medical Services
Yes
No
1. Medical Care
2. Alcohol/Drug Testing
3. HIV/AIDS Medical Support and Testing
4. Other Medical Services (Specify)
After Care Services
Yes
No
1. Continuing Care
2. Relapse Prevention
3. Recovery Coaching
4. Self-Help and Support Groups
5. Spiritual Support
6. Other After Care Services (Specify)
Education Services
Yes
No
1. Substance Abuse Education
2. HIV/AIDS Education
3. Other Education Services (Specify)
Peer-to-Peer Recovery Support Services
Yes
No
1. Peer Coaching or Mentoring
2. Housing Support
3. *Alcohol-and-Drug-Free Social Activities*
4. Information and Referral
5. Other Peer-to-Peer Recovery Support Services (Specify)
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A. Demographics
ASK ONLY AT INTAKE/BASELINE
1. What is your gender?
MALE
FEMALE
TRANSGENDER
REFUSED
2. Are you Hispanic or Latino
YES
NO
REFUSED
[IF YES] What ethnic group do you consider yourself? Please answer yes or no for each of the following. You may say yes to more than one.
Yes
No
Refused
Central American
Cuban
Dominican
Mexican
Puerto Rican
South American
Other? If so, specify below
Specify if selected above.
3. What is your race? Please answer yes or no for the following. You may say yes to more than one.
Yes
No
Refused
Black or African American
Asian
Native Hawaiian or other Pacific Islander
Alaska Native
White
American Indian
4. What is your date of birth? [THE SYSTEM WILL ONLY SAVE MONTH AND YEAR. TO MAINTAIN CONFIDENTIALITY, DAY IS NOT SAVED.]
-
Month
-
Day
Year
Date
Did the client refuse to share their date of birth?
YES
NO
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A. MILITARY FAMILY AND DEPLOYMENT
5. Have you ever served in the Armed Forces, in the Reserves, or in the National Guard? [IF SERVED] In which area, the Armed Forces, Reserves, or National Guard did you serve
NO
YES, IN THE ARMED FORCES
YES, IN THE RESERVES
YES, IN THE NATIONAL GUARD
REFUSED
DON'T KNOW
[IF NOT, REFUSED, OR DON'T KNOW, SKIP TO QUESTION A6.]
5a. Are you currently on active duty in the Armed Forces, in the Reserves, or in the National Guard? [IF ACTIVE] In which area, the Armed Forces, Reserves, or National Guard?
NO, SEPARATED OR RETIRED FROM THE ARMED FORCES, RESERVES, OR NATIONAL GUARD
YES, IN THE ARMED FORCES
YES, IN THE RESERVES
YES, IN THE NATIONAL GUARD
REFUSED
DON'T KNOW
5b. Have you ever been deployed to a combat zone? [CHECK ALL THAT APPLY.]
NEVER DEPLOYED
IRAQ OR AFGHANISTAN (E.G., Operation Enduring Freedom [OEF]/ Operation Iraqi Freedom [OIF]/ Operation New Dawn [OND])
PERSIAN GULF (OPERATION DESERT SHIELD/DESERT STORM
VIETNAM/SOUTHEAST ASIA
KOREA
WWII
DEPLOYED TO A COMBAT ZONE NOT LISTED ABOVE (E.G., BOSNIA/SOMALIA)
REFUSED
DON'T KNOW
6. Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves, or in the National Guard or separated or retired from the Armed Forces, Reserves, or National Guard?
NO
YES, ONLY ONE
YES, MORE THAN ONE
REFUSED
DON'T KNOW
[IF NO, REFUSED, OR DON'T KNOW, SKIP TO SECTION B.]
[IF YES, ANSWER FOR UP TO 6 PEOPLE]
DO YOU NEED TO ADD A PERSON?
YES
NO
What is the relationship to the person?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Has the Service Member experienced any of the following?
YES
NO
REFUSED
DON'T KNOW
6a. Deployed in support of combat operations (e.g., Iraq or Afghanistan)
6b. Was physically injured during combat operations?
6c. Developed combat stress symptoms/difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
6d. Died or was killed?
DO YOU NEED TO ADD A PERSON?
YES
NO
What is the relationship to the person?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Has the Service Member experienced any of the following?
YES
NO
REFUSED
DON'T KNOW
6a. Deployed in support of combat operations (e.g., Iraq or Afghanistan)
6b. Was physically injured during combat operations?
6c. Developed combat stress symptoms/difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
6d. Died or was killed?
DO YOU NEED TO ADD A PERSON?
YES
NO
What is the relationship to the person?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Has the Service Member experienced any of the following?
YES
NO
REFUSED
DON'T KNOW
6a. Deployed in support of combat operations (e.g., Iraq or Afghanistan)
6b. Was physically injured during combat operations?
6c. Developed combat stress symptoms/difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
6d. Died or was killed?
DO YOU NEED TO ADD A PERSON?
YES
NO
What is the relationship to the person?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Has the Service Member experienced any of the following?
YES
NO
REFUSED
DON'T KNOW
6a. Deployed in support of combat operations (e.g., Iraq or Afghanistan)
6b. Was physically injured during combat operations?
6c. Developed combat stress symptoms/difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
6d. Died or was killed?
DO YOU NEED TO ADD A PERSON?
YES
NO
What is the relationship to the person?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Has the Service Member experienced any of the following?
YES
NO
REFUSED
DON'T KNOW
6a. Deployed in support of combat operations (e.g., Iraq or Afghanistan)
6b. Was physically injured during combat operations?
6c. Developed combat stress symptoms/difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
6d. Died or was killed?
DO YOU NEED TO ADD A PERSON?
YES
NO
What is the relationship to the person?
Mother
Father
Brother
Sister
Spouse
Partner
Child
Has the Service Member experienced any of the following?
YES
NO
REFUSED
DON'T KNOW
6a. Deployed in support of combat operations (e.g., Iraq or Afghanistan)
6b. Was physically injured during combat operations?
6c. Developed combat stress symptoms/difficulties adjusting following deployment, including post-traumatic stress disorder (PTSD), depression, or suicidal thoughts?
6d. Died or was killed?
B. DRUG AND ALCOHOL USE
1. During the past 30 days, how many days have you used the following?
Number of Days
REFUSED
DON'T KNOW
a. Any Alcohol (IF ZERO, SKIP TO ITEM B1c.)
b. Alcohol to intoxication (5+ drinks in one sitting)
b2. Alcohol to intoxication (4 or fewer drinks in one sitting and felt high)
c. Illegal drugs [IF B1a OR B1c=0, REFUSED (RF), DON'T KNOW (DK), THEN SKIP TO ITEM B2.]
d. Both alcohol and drugs (on the same day)
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).
2. During the past 30 days, how many days have you used any of the following: [IF THE VALUE IN ANY ITEM B2a-B2i>0, THEN THE VALUE IN B1c MUST BE .0.]
Number of Days
RF
DK
Route*
RF
DK
a. Cocaine/Crack
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
b. Marijuana/Hashish(Pot, Joints, Blunts, Chronic, Weed, Mary Jane)
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
c. Opiates (skip to 1)
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
1. Heroin (Smack, H, Junk, Skag)
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
2. Morphine
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
3. Dilaudid
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
4. Demerol
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
5. Percocet
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
6. Darvon
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
7. Codeine
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
8. Tylenol 2,3,4
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
9. OxyCotin/Oxycodone
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
d. Non-prescription methadone
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
e. Hallucinogens/psychedelics, PCP (Angel dust, Ozone, Wack, Rocket Fuel), MDMA (Ecstacy, XTC, Adam), LSD (Acid, Boomers, Yellow Sunshine), Mushrooms, or Mescaline
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
f. Methamphetamine or other amphetamines (Meth, Uppers, Speed, Ice, Chalk, Crystal, Glass, Fire, Crank)
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
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).
2. During the past 30 days, how many days have you used any of the following: [IF THE VALUE IN ANY ITEM B2a-B2i>0, THEN THE VALUE IN B1c MUST BE .0.]
Number of Days
RF
DK
Route
RF
DK
g 1. Benzodiazepines: Diazepam (Valium); Alprazolam (Xanax); Triazolam (Halcion); and Estasolam (Prosom and Rohypnol, also known as roofies, roche, and cope
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
2. Barbiturates: Mephobarbital (Mebacut) and pentobarbital sodium (Nembutal)
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
3. Non-prescription GHB (known as Grievous Bodily Harm, Liquid Ecstasy, and Georgia Home Boy
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
4. Ketamine (known as Special K or Vitamin K
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
5. Other tranquilizers, downers, sedatives, or hypnotics
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
h. Inhalants (poppers, snappers, rush whippets)
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
i. other illegal drugs (specify below)
1. Oral
2. Nasal
3. Smoking
4. Non-intravenous (IV) injection
5. IV
Please specify the other drug they used in the last 30 days (if any)
In the past 30 days, have you injected drugs? [IF ANY ROUTE OF ADMINISTRATION IN B2a–B2i = 4 or 5, THEN B3 MUST = YES.
YES
NO
REFUSED
DON'T KNOW
In the past 30 days, how often did you use a syringe/needle, cooker, cotton, or water that someone else used?
Always
More than half the time
Half the time
Less than half the time
Never
REFUSED
DON'T KNOW
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C. FAMILY AND 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: OWN/RENT APARTMENT, ROOM, OR HOUSE
HOUSED: SOMEONE ELSE'S APARTMENT, ROOM, OR HOUSE
HOUSED: DORMITORY/COLLEGE RESIDENCE
HOUSED: HALFWAY HOUSE
HOUSED: RESIDENTIAL TREATMENT
REFUSED
DON'T KNOW
2. How satisfied are you with the conditions of your living space?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
REFUSED
DON’T KNOW
3. During the past 30 days, how stressful have things been for you because of your use of alcohol or other drugs? [IF B1a OR B1c > 0, THEN C3 CANNOT = “NOT APPLICABLE.”
Not at all
Somewhat
Considerably
Extremely
NOT APPLICABLE [USE ONLY IF B1A AND B1C = 0.] REFUSED
DON’T KNOW
4. During the past 30 days, has your use of alcohol or other drugs caused you to reduce or give up important activities? [IF B1a OR B1c>0, THEN C4 CANNOT = "NOT APPLICABLE."
Not at all
Somewhat
Considerably
Extremely
NOT APPLICABLE [USE ONLY IF B1A AND B1C = 0.]
REFUSED
DON'T KNOW
5. During the past 30 days, has your use of alcohol or other drugs caused you to have emotional problems? [IF B1a OR B1c > 0, THEN C5 CANNOT = “NOT APPLICABLE.”.”
Not at all
Somewhat
Considerably
Extremely
NOT APPLICABLE [USE ONLY IF B1A AND B1C = 0.] REFUSED
DON’T KNOW
6. [IF NOT MALE] Are you currently pregnant?
YES
NO
REFUSED
DON'T KNOW
7. Do you have children?
YES
NO
REFUSED
DON'T KNOW
a. How many children do you have? [If C7=YES, THEN THE VALUE IN C7a MUST BE .0.]
Number of children below
REFUSED
DON'T KNOW
How many children do you have
b. Are any of your children living with someone else due to a child protection court order?
YES
NO
REFUSED
DON'T KNOW
c. [IF YES] How many of your children are living with someone else due to a child protection court order? [THE VALUE IN C7c CANNOT EXCEED THE VALUE IN C7a.]
Number of children below
REFUSED
DON'T KNOW
c. [IF YES] How many of your children are living with someone else due to a child protection court order? [THE VALUE IN C7c CANNOT EXCEED THE VALUE IN C7a.]
For how many of your children have you lost parental rights? [THE CLIENT’S PARENTAL RIGHTS WERE TERMINATED.] [THE VALUE IN ITEM C7d CANNOT EXCEED THE VALUE IN C7a.]
Number of children below
REFUSED
DON'T KNOW
d. For how many of your children have you lost parental rights? [THE CLIENT’S PARENTAL RIGHTS WERE TERMINATED.] [THE VALUE IN ITEM C7d CANNOT EXCEED THE VALUE IN C7a.]
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D. EDUCATION, EMPLOYMENT, AND INCOME
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
DON'T KNOW
2. What is the highest level of education you have finished, whether or not you received a degree?
NEVER ATTENDED
1ST GRADE
2ND GRADE
3RD GRADE
4TH GRADE
5TH GRADE
6TH GRADE
7TH GRADE
8TH GRADE
9TH GRADE
10TH GRADE
11TH GRADE
12TH GRADE/HIGH SCHOOL DIPLOMA/EQUIVALENT
COLLEGE OR UNIVERSITY/1ST YEAR COMPLETED
COLLEGE OR UNIVERSITY/2ND YEAR COMPLETED/ASSOCIATES'S DEGREE (AA,AS)
COLLEGE OR UNIVERSITY/3RD YEAR COMPLETED
BACHELOR'S DEGREE (BA,BS) OR HIGHER
VOCATIONAL/TECHNICAL (VOC/TECH) PROGRAM AFTER HIGH SCHOOL BUT NO VOC/TECH DIPLOMA
VOC/TECH DIPLOMA AFTER HIGH SCHOO
REFUSED
DON'T KNOW
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 “ENROLLED, FULL TIME” IN D1 AND INDICATES “EMPLOYED, FULL TIME” IN D3, ASK FOR CLARIFICATION. IF CLIENT IS INCARCERATED AND HAS NO WORK OUTSIDE OF JAIL, CODE D3 AS “UNEMPLOYED, NOT LOOKING FOR WORK.”]
EMPLOYED, FULL TIME (35+ HOURS PER WEEK, OR WOULD HAVE BEEN)
EMPLOYED, PART TIME
UNEMPLOYED, LOOKING FOR WORK
UNEMPLOYED, DISABLED
UNEMPLOYED, VOLUNTEER WORK
UNEMPLOYED, RETIRED
UNEMPLOYED, NOT LOOKING FOR WORK
REFUSED
DON’T KNOW
4. Approximately, how much money did YOU receive (pre-tax individual income) in the past 30 days from … [IF D3 DOES NOT = “EMPLOYED” AND THE VALUE IN D4a IS GREATER THAN ZERO, PROBE. IF D3 = “UNEMPLOYED, LOOKING FOR WORK” AND THE VALUE IN D4b = 0, PROBE. IF D3 = “UNEMPLOYED, RETIRED” AND THE VALUE IN D4c = 0, PROBE. IF D3 = “UNEMPLOYED, DISABLED” AND THE VALUE IN D4d = 0, PROBE.
Number $
RF
DK
a. Wages
b. Public assistance
c. Retirement
d. Disability
e. Non-legal income
f. Family and/or Friends
g. Other (Specify Below)
Other income (from above)
5. Have you enough money to meet your needs?
Not at all
A little
Moderately
Mostly
Completely
REFUSED
DON'T KNOW
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E. CRIME AND CRIMINAL JUSTICE STATUS
TIMES
RUFUSED
DON'T KNOW
1. In the past 30 days, how many times have you been arrested? [IF NO ARRESTS, SKIP TO ITEM E3.]
2. In the past 30 days, how many times have you been arrested from drug-related offenses? [THE VALUE IN E2 CANNOT BE GREATER THAN THE VALUE IN E1.]
NIGHTS
RUFUSED
DON'T KNOW
3. In the past 30 days, how many nights have you spent in jail/prison? [IF THE VALUE IN E3 IS GREATER THAN 15, THEN C1 MUST = INSTITUTION (JAIL/PRISON). IF C1 = INSTITUTION (JAIL/PRISON), THEN THE VALUE IN E3 MUST BE GREATER THAN OR EQUAL TO 15.]
TIMES
RUFUSED
DON'T KNOW
4. In the past 30 days, how many times have you committed a crime? [CHECK NUMBER OF DAYS USED ILLEGAL DRUGS IN ITEM B1c. ANSWER HERE IN E4 SHOULD BE EQUAL TO OR GREATER THAN NUMBER IN B1c BECAUSE USING ILLEGAL DRUGS IS A CRIME.]
5. Are you currently awaiting charges, trial, or sentencing?
YES
NO
REFUSED
DON'T KNOW
6. Are you currently on parole or probation?
YES
NO
REFUSED
DON'T KNOW
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F. MENTAL AND PHYSICAL HEALTH PROBLEMS AND TREATMENT AND RECOVERY
1. How would you rate your overall health right now?
Excellent
Very good
Good
Poor
REFUSED
DON'T KNOW
2. During the past 30 days, did you receive:
YES
[IF YES] Altogether for how many nights
NO
RF
DK
a. Impatient treatment for: i. Physical complaint
a. Impatient treatment for: ii. mental or emotional difficulties
a. Impatient treatment for iii. Alcohol or substance abuse
2. During the past 30 days, did you receive:
YES
[IF YES] Altogether for how many nights
NO
RF
DK
b. Outpatient treatment for i. Physical complaint
b. Outpatient treatment for ii. Mental or emotional difficulties
b. Outpatient treatment for iii. Alcohol or substance abuse
2. During the past 30 days, did you receive:
YES
[IF YES] Altogether for how many nights
NO
RF
DK
c. Emergency room treatment for i. Physical complaint
c. Emergency room treatment for ii. Mental or emotional difficulties
c. Emergency room treatment for iii. Alcohol or substance abuse
During the past 30 days, did you engage in sexual activity?
Yes
No
NOT PERMITTED TO ASK
DON'T KNOW
Altogether, how many:
Contacts
RF
DK
a. Sexual contacts (vaginal, oral, or anal) did you have?
b. Unprotected sexual contacts did you have? [THE VALUE IN F3b. SHOULD NOT BE GREATER THAN THE VALUE IN F3a.] [IF ZERO, SKIP TO F4.]
c. Unprotected sexual contacts were with an individual who is or was [NONE OF THE VALUES IN F3c1–F3c3 CAN BE GREATER THAN THE VALUE IN F3b.] 1. HIV positive or has AIDS
c. Unprotected sexual contacts were with an individual who is or was [NONE OF THE VALUES IN F3c1–F3c3 CAN BE GREATER THAN THE VALUE IN F3b.] 2. An injection drug user
c. Unprotected sexual contacts were with an individual who is or was [NONE OF THE VALUES IN F3c1–F3c3 CAN BE GREATER THAN THE VALUE IN F3b.] 3. High on some substance
Have you ever been tested for HIV?
Yes
No
REFUSED
DON'T KNOW
Do you know the results of your HIV testing?
Yes
No
5. How would you rate your quality of life?
Very poor
Poor
Neither poor nor good
Good
Very good
REFUSED
DON'T KNOW
6. How satisfied are you with your health?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
REFUSED
DON'T KNOW
7. Do you have enough energy for everyday life?
Not at all
A little
Moderately
Mostly
Completely
REFUSED
DON'T KNOW
8. How satisfied are you with your ability to perform your daily activites?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
REFUSED
DON'T KNOW
9. How satisfied are you with yourself?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
REFUSED
DON'T KNOW
10. In the past 30 days, not due to your use of alcohol or drugs, how many days have you:
Days
RF
DK
a. Experienced serious depression
Yes
No
b. Experienced serious anxiety or tension
Yes
No
c. Experienced hallucinations
Yes
No
d. Experienced trouble understanding, concentrating, or remembering
Yes
No
e. Experienced trouble controlling violent behavior
Yes
No
f. Attempted suicide
Yes
No
g. Been prescribed medication for psychological/emotional problem
Yes
No
[IF CLIENT REPORTS ZERO DAYS, RF, OR DK, TO ALL ITEMS IN QUESTION F10, SKIP TO ITEM F12
11. How much have you been bothered by these psychological or emotional problems in the past 30 days?
Not at all
Slightly
Moderately
Considerable
Extremely
REFUSED
DON'T KNOW
12. Have you ever experienced violence or trauma in any setting (including community or school violence; domestic violence; physical, psychological, or sexual maltreatment/assault within or outside of the family; natural disaster; terrorism; neglect; or traumatic grief)?
YES
NO
REFUSED
DON'T KNOW
Did any of these experiences feel so frightening, horrible, or upsetting that, in the past and/or the present, you:
12a. Have had nightmares about it or thought about it when you did not want to?
YES
NO
REFUSED
DON'T KNOW
12b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it?
YES
NO
REFUSED
DON'T KNOW
12c. Were constantly on guard, watchful, or easily startled?
YES
NO
REFUSED
DON'T KNOW
12d. Felt numb and detached from others, activities, or your surroundings?
YES
NO
REFUSED
DON'T KNOW
13. In the past 30 days, how often have you been hit, kicked, slapped, or otherwise physically hurt?
Never
A few times
More than a few times
REFUSED
DON'T KNOW
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G. SOCIAL CONNECTEDNESS
1. In the past 30 days, did you attend any voluntary self-help groups for recovery that were not affiliated with a religious or faith-based organization? In other words, did you participate in a nonprofessional, peeroperated organization that is devoted to helping individuals who have addiction-related problems, such as Alcoholics Anonymous, Narcotics Anonymous, Oxford House, Secular Organization for Sobriety, or Women for Sobriety, etc.?
YES
NO
REFUSED
DON'T KNOW
[IF YES] SPECIFY HOW MANY TIME
NUMBER
REFUSED
DON'T KNOW
SPECIFY HOW MANY TIMES
2. In the past 30 days, did you attend any religious/faith-based-affiliated recovery self-help groups?
YES
NO
REFUSED
DON'T KNOW
[IF YES] SPECIFY HOW MANY TIMES
NUMBER
REFUSED
DON'T KNOW
SPECIFY HOW MANY TIMES
3. In the past 30 days, did you attend any meetings of organizations that support recovery other than the organizations described above?
YES
NO
REFUSED
DON'T KNOW
[IF YES] SPECIFY HOW MANY TIMES
NUMBER
REFUSED
DON'T KNOW
SPECIFY HOW MANY TIMES
4. In the past 30 days, did you have interaction with family and/or friends that are supportive of your recovery?
YES
NO
REFUSED
DON'T KNOW
5. To whom do you turn when you are having trouble? [SELECT ONLY ONE.]
NO ONE
CLERGY MEMBER
FAMILY MEMBER
FRIENDS
REFUSED
DON'T KNOW
6. How satisfied are you with your personal relationships?
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisified
REFUSED
DON'T KNOW
Submit
Should be Empty: