Form ASI - Part B ASI - Part B ASI - Part B

OMB # 0930- XXXX
Expiration Date: xx/xx/xxxx

PCAP Client Module

Addiction Severity Index 5th Edition - Intake Interview
Modification for Pregnant & Postpartum Women (Part B of 2 Parts)
Agency Name: ___________________________
Client #: __ __ __ __ __ __

Site Name: ______________________________
Date: __ __ / __ __ / __ __ __ __

INSTRUCTIONS:
Complete as soon as possible after birth.
Leave no blanks. Unless otherwise noted, as appropriate, code items:
-7 = Question not answered, client doesn’t know, doesn’t understand
-8 = Question not applicable
-9 = Question never asked
Space is provided at right for additional comments.

Assure client of confidentiality
G6.

Time Begun

___ ___ : ___ ___

Use 24 hr clock; code hours:minutes

G7.

(Include the question number with your notes)

Time Ended

___ ___ : ___ ___

Use 24 hr clock; code hours:minutes

G9.

TARGET CHILD INFORMATION COMMENTS

HRS

MINS

Contact Code
1 - PCAP Office
2 - Phone
5 - Other (tx center, client’s home)

______________________________________________________

___

______________________________________________________
______________________________________________________

Specify other: __________________________
G11. Interviewer Code Number

___ ___ ___

______________________________________________________

TARGET CHILD (TC) INFORMATION
TC1. Pregnancy Outcome (TC)

___

1 - Living
2 - Miscarried
3 - Terminated

______________________________________________________

4 - Stillborn
5 - Other (specify below)
Specify: _________________

______________________________________________________
______________________________________________________
______________________________________________________

TC2. Urine toxicology screens at delivery:
Ask client if you do not know.

a. Maternal

___

If positive, what for: _____________________________

______________________________________________________

b. Infant

___

______________________________________________________

If positive, what for: _____________________________
1 - No, not done
2 - Done, negative result

3 - Done, positive result
4 - Done, unknown result
-7 - Not known

TC3. Baby’s birthdate

______________________________________________________

__ __ /__ __ /__ __ __ __
m

m

d

d

y

y

y

___ ___
WKS

PROBE: was baby born premature? (<37 wks)

0 - No

y

1 - Yes

___

NOTE: If twins, code TC5 above as 1, complete and attach Twins Addendum, and code
TC6-TC11 with -8s (N/A).

TC6. Gender of baby

1 - Male

___ ___ ___ ___

______________________________________________________

OZ

____ ____ . ____
INCHES

ADAI Sound Data Source—1/24/2006
Page 1

______________________________________________________
______________________________________________________

LBS

TC8. Baby’s birth length

______________________________________________________

___

2 - Female

TC7. Baby’s birthweight

______________________________________________________
______________________________________________________

TC4. How far along were you when baby was
born? (gestational age)
TC5. Twins?

______________________________________________________

______________________________________________________
Parent-Child Assistance Program (PCAP)
University of Washington

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 OMB control
number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 15 minutes per client per year, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

TARGET CHILD (TC) INFORMATION (cont)
TC9.

TARGET CHILD INFORMATION COMMENTS

Was baby discharged from hospital when mom
was, or did s/he have to stay longer in the hospital?
Was s/he transferred to a special medical facility?

___

(Include the question number with your notes)

______________________________________________________

0 - No problems, baby discharged normally
1 - No special facility, but spent up to 2 weeks in the hospital
of delivery
2 - No special facility, but spent more than 2 weeks in the hospital
of delivery

______________________________________________________
______________________________________________________

3 - Went to a pediatric interim care facility

______________________________________________________

4 - Went to a Children’s Hospital

______________________________________________________

5 - Went to some other facility
6 - Other

______________________________________________________

TC10. IF BABY WAS DISCHARGED:
Where is the target baby living now?

___

OR IF NOT YET DISCHARGED:
Who will baby be going home with?
1 - Client

______________________________________________________
______________________________________________________

3 - Friend

2 - Relative
4 - Foster care
5 - Other, specify _________________________________

______________________________________________________

6 - Deceased

______________________________________________________

-7 - Mother doesn’t know
TC11. Who has legal custody of the baby?

___

1 - Client

3 - Friend

2 - Relative

4 - State

______________________________________________________
______________________________________________________

5 - Other, specify _________________________________
6 - Deceased

______________________________________________________

-7 - Mother doesn’t know
TC12. How involved is baby’s biological father?

___

1 - Involved to any degree
2 - Not at all involved

______________________________________________________

3 - Client doesn’t know who FOB is

______________________________________________________

If bio father not known, code -8s For TC13-TC15

TC13. Age of baby’s biological father?

___ ___

TC14. Race of baby’s biological father?
1 - Am. or Can. Indian, Alaska Native

4 - Hispanic

2 - Asian
3 - Black

5 - White

___

___

1

2

TC15. Highest grade in regular school baby’s biological
father has completed?

___ ___

Code 55 if bio father has GED and no further education.

Prenatal visits include only those times when you saw the doctor for prenatal
care while you were pregnant. It does not include ER visits, hospitalizations,
or doctor visits for other things. Talking to the doctor about your pregnancy
when you are there for other things doesn’t count as a prenatal visit.

Code date; use calendar.
None = 00/00/0000

ADAI Sound Data Source—1/24/2006

__ __ /__ __ /__ __ __ __
m m

d

______________________________________________________

______________________________________________________

0 - no other

TC16. When did you first see a doctor
for prenatal care?

______________________________________________________

______________________________________________________

6 - Other, specify _____________________________

Page 2

______________________________________________________

d

y

y

y

______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

y

______________________________________________________

Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

TARGET CHILD (TC) INFORMATION (cont)

TARGET CHILD INFORMATION COMMENTS
(Include the question number with your notes)

How many prenatal visits did you have:
Use calendar, prompt using months of the year
corresponding to the trimester.

______________________________________________________

TC16a.

in the 1st trimester?

___ ___

TC16b.

in the 2nd trimester?

___ ___

______________________________________________________

TC16c.

in the 3rd trimester?

___ ___

______________________________________________________

TC16d.

Total # of prenatal visits

___ ___
___

______________________________________________________

IF NOT PLANNED, did you consider an abortion?
0 - No
1 - Yes
-8 - N/A, pregnancy planned

___

______________________________________________________

Tubal ligation at delivery of target child?
0 - No
1 - Yes

___

______________________________________________________

TC17.

Was this pregnancy planned? 0 - No

TC18.
TC19.

1 - Yes

CONFIDENCE RATINGS

______________________________________________________

Is the above information significantly distorted by:
TC20. Client’s
misrepresentation?
0 - No
1 - Yes

___

TC21. Client’s inability to understand?
0 - No
1 - Yes

___

______________________________________________________
______________________________________________________
______________________________________________________

INTERVIEWER NEED RATING
TC99. At this time, how would you rate the target child’s
need for specialized medical intervention?

___

0 - No problems.

______________________________________________________

1 - Some problems, but seem to be under control with current
medical intervention.

______________________________________________________

2 - Need for more treatment in addition to target child’s current
treatment/services, but not apparently dangerous or greatly
interfering with target child’s life.
3 - Life threatening condition or urgent need for more treatment
and/or intervention in addition to target child’s current
treatment.

ADAI Sound Data Source—1/24/2006
Page 3

______________________________________________________

______________________________________________________
______________________________________________________

Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

ALCOHOL/DRUG USE DURING PREGNANCY

ALCOHOL/DRUG COMMENTS

During pregnancy: Record ILLEGAL DRUG USE ONLY (disregard prescribed drugs)
Use calendar, prompt using months of the year corresponding to the 1st trimester or month prior, and
2nd and 3rd trimesters.
DURING THIS PREGNANCY - ALCOHOL, CIGARETTES, & ILLEGAL DRUGS ONLY

(Include the question number with your notes)

___________________________________

Prompt for type of alcohol, code according to manual
1ST TRIMESTER &
MONTH PRIOR
2ND & 3RD TRIMESTER
FREQ

USUAL AMT

FREQ

USUAL AMT

___ ___

___

___ ___

___________________________________

___________________________________
___________________________________

D1.

Alcohol (any use at all)

___

D2.

Alcohol (> 5 drinks at a
time)

___

D3.

Heroin

___

___ ___ ___ ___

___

D4.

Methadone

___

___ ___ ___

___

___ ___ ___

D5.

Other opiates/analgesics

___

___

___

___

rel. amt.

___________________________________

D6.

Barbiturates

___

___

___

___

rel. amt.

___________________________________

D7.

Other sedatives/hypnotics/
tranquilizers

___

___

___

___

rel. amt.

___________________________________

D8.

Cocaine - all forms

___

___ . ___ ___

___

___ . ___ ___

# grams

___________________________________

D9.

Methamphetamine

___

___

___

___

rel. amt.

___________________________________

D9a.

Other amphetamines

___

___

___

___

rel. amt.

___________________________________

D10.

Cannabis (Marijuana)

___

___ . ___ ___

___

___ . ___ ___

# grams

___________________________________

D11.

Hallucinogens

___

___

___

___

rel. amt.

D12.

Inhalants

___

___

___

___

rel. amt.

D12a. Other (illicit only)

___

___

___

___

rel. amt.

D12b. Cigarettes

___

___ ___

___

___ ___

# cig/day

Specify: _______________________

___ ___

___ ___

___

Max. amt.

# drinks
# drinks

Max. amt.

___ ___ ___ ___ # mg
# mg

___________________________________
___________________________________
___________________________________

___________________________________
___________________________________
___________________________________
___________________________________

CODES:
Frequency Codes:

0 - never

2 - about once a month

4 - 1 or 2 days/week

6 - almost every day

1 - File Typeapplication/pdfFile Title3 ASIIntakeBwithtwin.pubAuthorShradLaFile Modified2009-07-13File Created2009-07-13