Download:
pdf |
pdfOMB # 0930- XXXX
Expiration Date: xx/xx/xxxx
Parent Child Assistance Program (PCAP)
Date of Exit ASI:
________________
ADDICTION SEVERITY INDEX — EXIT INTERVIEW
Current
Adv #: _______
Modified Interview for Pregnant & Postpartum Women
NOTICE TO STAFF: DO NOT SUBMIT THIS TOP SHEET TO DATA ENTRY.
REMOVE AND FILE SEPARATELY.
Family I.D. #
Mother's birthdate:
Interviewer:
Child’s Birthdate:
Tribal Affiliation and Enrollment Number:
Name of
child: (first)
Name of
mother: (first)
Name of
father:
Child's Gender:
Mom:____________________________________
(last)
(first)
Baby:
(middle)
(last)
(middle)
(last)
(middle)
(other)
(maiden/
other)
(other)
Who are you living with? Names and relationship:
Address:
City
Phone: (
)
State
Zip
Name phone listed under:
Do you have any plans to move in the next few months?
Are you employed outside the home now?
Where?
Phone: (
Type of work:
Are you in school?
(Where to?)
)
What/where?
Where do you take the child(ren) for checkups and medical care?
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 2 hours and 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 7-1044, Rockville, Maryland,20857.
Addiction Severity Index 5th Edition
University of Washington Modification for Pregnant & Postpartum Women (UWASI)
The UWASI is a modified version of the 5th edition of the ASI. It
includes all items from the 5th edition ASI along with additional
questions specific to pregnant and postpartum women. It contains 9
potential problem areas, as well as family/childhood history.
INTRODUCING THE ASI: Introduce and explain the nine potential
problem areas: Medical, Employment/Support Status, Alcohol, Drug,
Legal, Family/Social, Psychiatric, Children and Family Planning, and
Community Services and that some questions will also be asked about
childhood history. All clients receive this same standard interview. All
information gathered is confidential; explain what that means in your
facility; who has access to the information and the process for the release
of information.
There are two time periods we will discuss:
1) The past 30 days
2) Lifetime
Client Rating Scale: Client input is important. For each area, I will ask
you to use this scale to let me know how bothered you have been by any
problems in each section. I will also ask you how important treatment is
for you for the area being discussed.
The scale is:
0 - Not at all
1 - Slightly
2 - Moderately
3 - Considerably
4 - Extremely
Inform the client that he/she has the right to refuse to answer any question.
If the client is uncomfortable or feels it is too personal or painful to give an
answer, instruct the client not to answer. Explain the benefits and
advantages of answering as many questions as possible in terms of
developing a comprehensive and effective treatment plan to help them.
Please try not give inaccurate information!
When you interview, do not simply record information. Be sure that you
understand the intent of every question on the ASI so that you can
accurately convey that intent to the client. Probe, repeat, paraphrase until
you are sure the client understands what is being asked. Remember that as
the interviewer, you are responsible for the integrity of information
collected on the ASI.
Monitor the consistency of information provided by the client throughout
the interview. It is not acceptable to simply record what is reported.
—Paraphrased from the Preface to the Fifth Edition of the ASI Workbook (Barbara
Fureman, Gargi Parikh, Alicia Bragg, and A. Thomas McLellan, University of
Pennsylvania/Veterans Administration Center for Studies of Addiction).
HOLLINGSHEAD CATEGORIES (Licit work only):
1. Higher execs, major professionals, owners of large businesses
2. Business managers, proprietors of medium-sized businesses
($60,000-$175,000), lesser professionals (e.g., optician, pharmacist,
social worker, teacher [licensed], personnel manager, registered nurse).
3. Administrative managers and personnel, (e.g., appraiser, chief clerk,
insurance agent, private secretary, major sales representative), owners/
proprietors of small businesses (value under $60,000; e.g., bakery,
beauty hop, cigarette machines, convenience store, engraving business,
florist, decorator), minor professionals (e.g., actor, commercial artist,
credit manager, oral hygienist, piano teacher, reporter, travel agent).
4. Clerical and sales (e.g., bank clerk or teller, bill collector, bookkeeper,
car sales person, clerical worker, ferry worker, post office clerk, sales
clerk, shipping or warehouse clerk, secretary), technician (e.g., camp
counselor, dental technician, inspector, investigator, PBX operator,
window trimmer), proprietor of little business (e.g., flower shop, food
vendor, newsstand, sewing/tailor).
5. Skilled manual (usually having had training). Baker, chef,
cosmetician, barber, chef, electrician, fireman, hair stylist, lineman,
locksmith, machinist, massage therapist, mechanic, paperhanger,
painter, plumber, policeman, postal carrier, repairman, tailor (trained),
word processing.
6. Semi-skilled. Apprentice (electrician, printer, etc.), assembly line
worker, bartender, bus driver, checker, childcare in home (licensed,
trained), cocktail waitress, convenience store clerk, cook (short order),
daycare in a center (trained), delivery person, dressmaker (machine),
filing clerk, garage and gas station attendant, hairdresser, hospital aide,
housekeeper (some training), meter reader, trained nursing home aide,
practical nurse, painter, security guard, taxi driver, truck driver,
waitress (at one of the “better” places).
7. Unskilled. Amusement park workers (bowling alleys, pool rooms),
attendant, cafeteria worker, car wash attendants, childcare in home (no
training), construction helper, counterperson, domestic, home aide
(unlicensed), home piecework, hotel maid (little training), hospital
worker (unspecified), janitor, labor (unspecified), laundry worker,
messenger, parking lot attendant, porter, telephone solicitor, stock
handlers, waitress (“hash house”), welfare recipient. Include
unemployed.
8. Never employed.
PSYCHIATRIC DIAGNOSES:
See appendix in UWASI manual.
Note that FAS is a medical, not a psychiatric diagnosis.
INTERVIEWER INSTRUCTIONS:
1) Leave no blanks.
2) Make plenty of Comments (if another person reads this ASI, they
should have a relatively complete picture of the client's perceptions of
his/her problems).
3) -7 = Question not answered.
-8 = Question not applicable
4) When noting comments, please write the question number.
HALF TIME RULE:
If a question asks the number of months, round
up periods of 14 days or more to 1 month.
Round up 6 months or more to 1 year.
CONFIDENCE RATINGS:⇒ Last two items in each section.
⇒ Do not over-interpret.
⇒ Denial does not warrant
misrepresentation.
⇒ Misrepresentation = overt
contradiction in information.
Probe, cross-check and make plenty of comments!
ALCOHOL/DRUG USE INSTRUCTIONS:
Alcohol and Commonly Used Drugs: Drug terms and amounts. See appendix in
UWASI manual.
Code alcohol amounts by equivalent drinks:
Generally, 1 drink = 1 12-oz beer = 1 4-oz wine = 1 1.5-oz hard liquor (i.e., a
“single”). A single 40-ouncer is not 1 drink!
The following questions refer to two time periods: the past 30 days and lifetime.
Lifetime refers to the time prior to the last 30 days.
⇒ 30 day questions only require the number of days used.
⇒ Lifetime use is asked to determine extended periods of use.
⇒ Regular use = 3+ times per week, binges, or problematic irregular
use in which normal activities are compromised.
⇒ Alcohol to intoxication does not necessarily mean “drunk.” Use the
words “to feel or felt the effects,” “got a buzz,” “high,” etc. instead
of intoxication. As a rule of thumb, 3+ drinks in one sitting, or 5+
drinks in one day defines “intoxication.”
⇒ How to ask these questions:
→ “How many days in the past 30 have you used....?”
→ “How many years in your life have you regularly used....?”
PCAP Client Module
Addiction Severity Index 5th Edition - Exit Interview
Modification for Pregnant & Postpartum Women
Agency Name: ___________________________
Site Name: ______________________________
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
INSTRUCTIONS: Leave no blanks. Unless otherwise noted, where appropriate, code items:
-7 = Question not answered, client doesn’t know, doesn’t understand
-8 = Question not applicable
-9 = Question never asked
*The missing item numbers refer to items that appear on the Intake ASI but not on the Exit ASI interview*
Space is provided at right for additional comments.
Assure client of confidentiality
GENERAL INFORMATION
A.
GENERAL INFORMATION COMMENTS
Three years after date consent signed
m m
d
B.
Current Advocate #
C.
# of Advocates this client has had over the
36 months in program
d
y
y
y
y
Date of interview
___
d
d
y
y
y
y
___ ___ : ___ ___
Time Begun
Use 24 hr clock; code hours:minutes
G7.
___ ___ : ___ ___
Time Ended
Use 24 hr clock; code hours:minutes
G9.
HRS
Contact Code
1 - PCAP Office
2 - Phone
MINS
___
3 - Prison
4 - Jail
5 - Other (such as treatment center, client’s home)
Specify other: __________________________
G11.
G19.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Specify other: ___________________________
How many days?
______________________________________________________
___
4 - Medical tx
5 - Psychiatric tx
6 - Other (specify below)
TOTAL days of past 30 in ALL controlled settings.
If G19 is No, code -8.
______________________________________________________
__ __ __ __ __
______________________________________________________
A place, theoretically, without access to alcohol/drugs; halfway house generally
not controlled environment. If more than one environment, code where majority
of time.
G20.
______________________________________________________
______________________________________________________
Have you been in a controlled environment
in the past 30 days?
1 - No
2 - Jail/prison
3 - Alcohol or drug tx
______________________________________________________
___ ___ ___
Interviewer Code Number
G15a. Zip code of client
______________________________________________________
______________________________________________________
__ __ /__ __ /__ __ __ __
m m
G6.
______________________________________________________
___ ___ ___
List all advocates by ID, (# months in parentheses):
_________________________________________________
G5.
(Include the question number with your notes)
__ __ /__ __ /__ __ __ __
Target Exit Date
___ ___
______________________________________________________
______________________________________________________
Place your message here. For maximum impact, use two or three sentences.
ADAI Sound Data Source—3/2/2007
Page 1
Parent-Child Assistance Program (PCAP)
University of Washington
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
MEDICAL STATUS
MEDICAL COMMENTS
(Include the question number with your notes)
Note: Restrict to physical medical problems only. Do not
include psychiatric problems, or physical problems due
only to alcohol or drug use (both will be recorded
elsewhere).
M1.
M3.
______________________________________________________
___ ___
______________________________________________________
Overnight, not simple E.R. Normal childbirth not counted, but complications in
childbirth are. Include o.d.’s, d.t.’s. Do not include detox, psych or rehab
hospitalization.
PROBE for injury, assault, car accident.
______________________________________________________
Since enrollment, how many times have you been
hospitalized for medical problems?
Do you have any chronic medical problems which
continue to interfere with your life? (Include FAS/FAE
diagnosis)
0 - No
1 - Yes
______________________________________________________
______________________________________________________
Specify: ________________________________
Requiring continuous or regular care on the part of client, not a temporary
condition. Examples of chronic medical problems: ulcers, cirrhosis, heart
conditions, hepatitis, hypertension, AIDS-related problems, abscesses of the
arms/legs, etc.
Not minor allergies, need for reading glasses, etc.
To determine whether or not a medical problem is related only to drugs and
alcohol, (therefore not coded here), ask yourself, if she stopped using, would
this problem disappear without medical tx?
M4.
Are you taking any prescribed medication on a
regular basis for a physical problem?
0 - No
1 - Yes
___
M4b.
Since enrollment, have you been tested for HIV/AIDS?
0 - Never tested
3 - Tested, inconclusive results
1 - Tested, negative results 4 - Tested, never got results
2 - Tested, positive results
-7 - Don’t know
Date of last HIV/AIDS test (mo/yr)
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
__ __ / __ __
Mo
______________________________________________________
______________________________________________________
What? _________________________________
For above medical condition(s), legitimately prescribed, whether or not client
takes the med. Do not include meds for psychiatric conditions, or for shortterm or temporary conditions (like colds, detox), birth control pills, nicorette.
M4a.
______________________________________________________
___
Year
______________________________________________________
M4c.
Since enrollment, have you been tested for Hepatitis B?
Use codes from M4a
___
______________________________________________________
M4d.
Since enrollment, have you been tested for Hepatitis C?
Use codes from M4a
___
______________________________________________________
M4e.
Have you worked as a prostitute in the last 3 years
(for either drugs or money)?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
Specify: ________________________________
M5.
Do you receive a pension for a physical disability?
0 - No
1 - Yes
___
______________________________________________________
Includes Worker’s Comp.
Does not include psychiatric disability.
M6.
How many days have you experienced medical
problems in the past 30 days?
______________________________________________________
___ ___
______________________________________________________
Include only medical problems that would be present even if the client were to
become abstinent.
Include minor ailments such as colds or flu.
______________________________________________________
For Questions M7 & M8, ask client to use the Client’s Rating Scale
______________________________________________________
Have client restrict her responses to only those medical problems counted in M6.
M7.
How troubled or bothered have you been by these
medical problems in the past 30 days?
___
______________________________________________________
M8.
How important to you now is treatment for these
medical problems?
___
______________________________________________________
ADAI Sound Data Source—3/2/2007
Page 2
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
MEDICAL STATUS (cont)
MEDICAL COMMENTS
(Include the question number with your notes)
CONFIDENCE RATINGS
Is the above information significantly distorted by:
M10. Client’s misrepresentation?
0 - No
1 - Yes
______________________________________________________
___
______________________________________________________
In all sections this means contradictory information has been presented by the
client, conflicting reports that the client cannot justify.
It does not mean a simple “gut hunch.” Disregard client’s demeanor.
M11. Client’s inability to understand?
0 - No
1 - Yes
___
___
______________________________________________________
01-
No medical problems, no need.
Medical problems, but current tx has brought condition to a
controlled, non-problematic state.
2-
Need for more tx in addition to client’s current tx, but not
immediately life-threatening.
______________________________________________________
3-
Urgent need for more tx in addition to client’s current tx. Should
be a high advocate priority.
______________________________________________________
ADAI Sound Data Source—3/2/2007
Page 3
______________________________________________________
______________________________________________________
INTERVIEWER CLIENT NEED RATING
M99. How would you rate this client’s need for medical
treatment?
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
EMPLOYMENT/SUPPORT STATUS
E1.
Education completed
EMPLOYMENT/SUPPORT COMMENTS
__ __ / __ __
Code GED 55 yrs, 00 mos
Yrs
Mos
If more than GED, code highest level; formal education only.
E2.
Since enrollment, training or technical
education completed
__ __
Formal, organized training only. Code # months
completed, whether or not program completed.
E2a. Since enrollment, what types of educational/
training programs have you completed (or are
currently in progress)?
0 - No, none, no more
1 - High school
2 - Trade/vocational program
3 - College/university (4 yr)
1. ___
2. ___
3. ___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
1. ___
2. ___
3. ___
E2c. Are you in school now?
______________________________________________________
______________________________________________________
___
Code type, using codes from E2a above.
E3.
______________________________________________________
______________________________________________________
Specify other: _________________________
Use codes from E2a above.
______________________________________________________
Mos
4 - GED program
5 - Community college
6 - Back-to-work program
7 - Other
E2b. Since enrollment, have you been involved in
any (other) schooling that you dropped/quit?
(Include the question number with your notes)
______________________________________________________
Do you have a profession, trade, or skill?
0 - No
1 - Yes
___
______________________________________________________
Specify in detail: __________________________________
______________________________________________________
Any employable, transferable skill acquired through specialized training or
education.
E4.
Do you have a valid driver’s license?
0 - No
1 - Yes
___
Valid license; not suspended/revoked.
______________________________________________________
______________________________________________________
E4a. Do you have another form of picture identification?
0 - No
1 - Yes
___
______________________________________________________
Must be legal, not forged or borrowed.
E4b. Is transportation usually a problem for you?
0 - No
1 - Yes
___
______________________________________________________
E5.
___
______________________________________________________
Do you have an automobile available for use?
0 - No
1 - Yes
If answer to E4 is No, then E5 must be No.
Does not require ownership, only requires availability on a regular basis.
E7.
Usual (or last) occupation
______________________________________________________
___
Specify in detail: ______________________________
Code appropriate Hollingshead Category.
No usual occupation, record last job.
Code 8 only when client has not worked at all.
E8.
______________________________________________________
Does someone (a person) contribute to your
support in any way?
0 - No
1 - Yes
___
Does this constitute the majority of your support?
0 - No
1 - Yes
______________________________________________________
___
______________________________________________________
If E8 is No, then E9 is -8. If information from E12-E17 does not confirm this
initial response, clarify any discrepancy.
E9a. Have you worked for pay since enrollment?
0 - Has not worked for pay
1 - Has worked only intermittently;
few hours or days at a time
4 - Part-time + illicit work
5 - Full-time + illicit work
2 - Worked part-time
6 - Illicit work only
______________________________________________________
______________________________________________________
Regular support in form of cash, housing, food.
Include spouse's contribution.
Exclude institutionalized support.
E9.
______________________________________________________
______________________________________________________
___
______________________________________________________
______________________________________________________
3 - Worked full-time
ADAI Sound Data Source—3/2/2007
Page 4
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
EMPLOYMENT/SUPPORT STATUS (cont)
E9b. How long was your longest full-time or regular
part-time job since enrollment?
EMPLOYMENT/SUPPORT COMMENTS
__ __ / __ __
Yrs
Mos
______________________________________________________
Even if client later went back on welfare.
E10. Usual employment pattern, past 3 years
___
5 - Military service
6 - Retired/disability
7 - Unemployed
8 - In controlled environment
Most representative, not necessarily most recent. If equal times for more than
one category, code most current. Includes "under the table" jobs. Jobs in prison
are not counted as employment.
E11. How many days were you paid for working in
the past 30?
___ ___
Include paid sick/vacation days, “under-the-table” work.
Jobs in prison are NOT counted.
E12.
Remind client of confidentiality if client is reluctant to answer.
Focus here is on amount of CASH available to client, not
on estimate of client’s net worth.
Employment
Net income, take home pay, include “under the table”
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
How much money did you receive from the following sources in
the past 30 days?
NOTE:
______________________________________________________
___
E9c. Since enrollment, have you been able to go off public
assistance because you were working?
0 - No
1 - Yes
-8 - Never on public assistance
1 - Full time (> 35 hrs/wk)
2 - Part time (regular hrs)
3 - Part time (irregular, daywork)
4 - Student
(Include the question number with your notes)
______________________________________________________
______________________________________________________
$___,___ ___ ___
______________________________________________________
E13.
Unemployment compensation
$___,___ ___ ___
______________________________________________________
E14.
Welfare
$___,___ ___ ___
______________________________________________________
Specify Type(s): _____________________
______________________________________________________
E14a. Food stamps
$___,___ ___ ___
E15.
$___,___ ___ ___
______________________________________________________
$___,___ ___ ___
______________________________________________________
Pension, benefits or social security
Pensions for disability, SSI, worker’s comp
E15a. Tribal benefits
Specify Tribe: _______________________
E16.
Mate, family or friends (cash)
Money for personal expenses, pocket money
$___,___ ___ ___
______________________________________________________
______________________________________________________
ALSO Irregular sources of income
Settlements, legal gambling, income tax refund
E17.
$___,___ ___ ___
______________________________________________________
___ ___
______________________________________________________
Regular ongoing support. Do not include client herself or a self-supporting
spouse. Do include dependents who normally are supported by client but have
not been recently.
______________________________________________________
Illegal (Cash only)
Do not attempt to convert drugs to cash
E18.
How many people depend on you for the majority
of their food, shelter, etc.?
ADAI Sound Data Source—3/2/2007
Page 5
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
EMPLOYMENT/SUPPORT STATUS (cont)
NOTE:
E19.
EMPLOYMENT/SUPPORT COMMENTS
In the case where the client has not had an opportunity to work (incarcerated,
in treatment, etc.), it is, by definition, not possible for her to have had
employment problems. Therefore, code -8’s for E19-E21.
How many days have you experienced employment
problems in the past 30?
For Questions E20 & E21, ask client to use the Client’s Rating Scale
How troubled or bothered have you been by these
employment problems?
How important to you now is counseling for these
employment problems?
______________________________________________________
______________________________________________________
______________________________________________________
___
______________________________________________________
Restrict to those identified in E19.
E21.
______________________________________________________
___ ___
Include problems finding work only if client has been trying. Do not record here
if problems are entirely due to alcohol/drug use (record in Alcohol/Drug
section), or if they are entirely due to interpersonal social skills (record in
Family/Social section).
E20.
(Include the question number with your notes)
___
CONFIDENCE RATINGS
______________________________________________________
______________________________________________________
Is the above information significantly distorted by:
E23. Client’s misrepresentation?
0 - No
1 - Yes
___
______________________________________________________
E24.
Client’s inability to understand?
0 - No
1 - Yes
___
______________________________________________________
E99.
How would you rate this client’s need for employment
counseling?
INTERVIEWER CLIENT NEED RATING
0-
No employment problems, working, no need.
1-
No employment problems because no employment, client not
currently ready for employment.
2-
Employment problems, employed.
3-
Employability problems, unemployed.
ADAI Sound Data Source—3/2/2007
Page 6
______________________________________________________
___
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
ALCOHOL/DRUG USE (ILLICIT & PRESCRIPTION)
• Include licit, prescription drugs in appropriate categories. If only drug used in that category is prescription, code 1 in “prescription only” box (otherwise-0).
• Ask past 30 days first. Lifetime use=extended period of regular use (regular use=freq. of ≥3 times/week OR any use over a period of time that is problematic for the client, e.g.
binge use).
If total period of reg. use less than 6 months do not include in coding, but note in comments section. Six months or more counts to the next year. Substantial but irregular,
non-problematic use is not coded, but is noted in comments section.
• Alcohol to Intoxication is not necessarily getting drunk, but times client felt effect of alcohol, got a buzz. If client denies feeling effects of alcohol: the equivalent of 3 drinks in one
sitting (1–2 hours) can be considered alcohol to intoxication.
• If past 30 day and lifetime use = 0, then columns C-F should be coded -8, and columns G and H should be coded 0.
• NOTE: Anti-depressants are noted in comments, but not recorded on grid.
D1.
Alcohol (any use at all)
Wine coolers, beer, Cisco
D.
C. Prescription
Route
Only
of
0 - No
Admin 1 - Yes
F.
Last Time You
Ever Used
(Mo/Yr)
COMMENTS
(Include the question number with
your notes)
Past 30-day use pattern
H.
G.
Frequency Amount
A.
Past 30
Days
B.
Lifetime
(Years)
___ ___
___ ___
___
__ __ /__ __ __ __
___
__ __
# drinks
# drinks
D2.
Alcohol (to intoxication)
___ ___
___ ___
___
__ __ /__ __ __ __
___
__ __
D3.
Heroin
___ ___
___ ___
___
__ __ /__ __ __ __
___
__ __ __ __
# mg
___ ___
___ ___
___
___
__ __ /__ __ __ __
___
__ __ __
# mg
___ ___
___ ___
___
___
__ __ /__ __ __ __
___
___ ___
___ ___
___
___
__ __ /__ __ __ __
___
___ ___
___ ___
___
___
__ __ /__ __ __ __
___
___ ___
___ ___
___
__ __ /__ __ __ __
___
___ ___
___ ___
___
__ __ /__ __ __ __
___
___ ___
___ ___
___
__ __ /__ __ __ __
___
___ ___
___ ___
___
__ __ /__ __ __ __
___
___ ___
___ ___
___
__ __ /__ __ __ __
___
___ ___
___ ___
___
__ __ /__ __ __ __
___
Smack, horse, dove, china white, tar
D4.
Methadone
LAAM, Dolophine
D5.
Other opiates/analgesics
Morphine, Demerol, Percocet,
Darvon, Codeine, Robitussin
D6.
Barbiturates
Downers, reds, Seconal, Amytal,
Phenobarbitol
D7.
Other sed/hyp/tranquilizers
Valium, Librium, Thorazine, Tofranil,
Quaaludes
D8.
Cocaine - all forms
Crack, freebase, base, rock, coke
powder, soup, crack, candy, line
D9.
Methamphetamine
Crank, crystal meth, chalk, L.A.
D9a.
Other amphetamines
Speed, race, ice, white cross, amp
D10.
Cannabis (Marijuana)
Weed, pot, bud, grass, hashish
D11.
# grams
__ . __ __
# grams
Hallucinogens
LSD, acid, Mescaline, Mushrooms,
Psylocybin, PCP (Phencyclidine),
angel dust, Peyote, PMA
D12.
___
__ . __ __
Inhalants
Nitrous Oxide, Amyl Nitrate, Poppers,
glue, solvents
D12a. Other (illicit only)
List ingredients of Other drug if known
e.g., “club” drugs (ecstasy, etc.),
steroids, formaldehyde
___ ___
___ ___
___
__ __ /__ __ __ __
___
___ ___
___ ___
___
__ __ /__ __ __ __
___
___ ___
___ ___
Specify:
__________________________
D12b. Cigarettes or chewing tobacco
D13.
More than one substance
per day
__ __
# cig/day
Includes alcohol, but not cigarettes
Routes of Admin:
1 - Oral
2 - Nasal (sniff, snort)
3 - Smoking
4 - Non IV inj (skin popping)
5 - IV injection
If more than one route of administration, choose most severe (i.e., highest applicable code)
Frequency Codes:
D14.
0 - never
2 - about once a month
4 - 1 or 2 days/week
6 - almost every day
1 - 6
D20b. Drug abuse
___
______________________________________________________
# times; Code 6 if > 6
Since enrollment, how many times have you had outpatient
treatment for:
D20c. Alcohol abuse
______________________________________________________
___
______________________________________________________
___
______________________________________________________
# times; Code 6 if > 6
D20d. Drug abuse
# times; Code 6 if > 6
D21.
For D19 and D20, any type tx includes inpatient, outpatient, detox, halfway
house, and/or AA/NA (if ≥3 session/mo). For D19, D20, D20a-D20d, if tx for
alcohol and drugs simultaneously, count both places.
______________________________________________________
How many of these were detox only?
Alcohol
______________________________________________________
___ ___
Referring to D19. If D19 = 0, then D21 = -8
D22.
Drug
___ ___
______________________________________________________
Referring to D20. If D20 = 0, then D22 = -8
ADAI Sound Data Source—3/2/2007
Page 8
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
ALCOHOL/DRUG USE (cont)
ALCOHOL/DRUG COMMENTS
D22a. Since enrollment, what types of alcohol/drug treatment have you
been involved in?
Treatment Codes
00 - No treatment
01 - Inpatient (30 day)
02 - Inpatient (>30 day)
03 - Outpatient
04 - Counseling
05 - Self-help groups
06 07 08 09 -
Outcome Codes
0 - no (further) tx
1 - assessed, referred
but never started
2 - started, dropped
3 - started, in process
4 - completed tx
(AA, NA, ACOA)
Methadone (drug maintenance only)
Methadone (maint’ence & counseling)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Treatment
Outcome
Outcome
1.
___ ___
___
5.
___ ___
___
2.
___ ___
___
6.
___ ___
___
3.
___ ___
___
7.
___ ___
___
4.
___ ___
___
8.
___ ___
___
______________________________________________________
______________________________________________________
D22b. If in inpatient tx, did your children stay with you
at the tx center?
0 - No
1 - Yes
-8 - N/A
___
D22c. If in inpatient tx, was it a program just for women?
0 - No
1 - Yes
-8 - N/A
___
D23.
Alcohol
$___,___ ___ ___
D24.
Drugs
$___,___ ___ ___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Enter only money actually spent, not street value.
How many days have you been treated in an
outpatient setting for alcohol or drugs in the past
30 days?
______________________________________________________
______________________________________________________
How much money would you say you spent during the past 30
days on:
D25.
______________________________________________________
______________________________________________________
Transitional hsg with outpatient services
Other___________________________
Treatment
(Include the question number with your notes)
___ ___
Include NA, AA, meth. maint.
______________________________________________________
______________________________________________________
How many days in the past 30 have you experienced:
D26.
D27.
Alcohol problems
___ ___
Drug problems
___ ___
Only problems directly related to use, e.g., cravings, withdrawal, disturbing
effects, wanting to stop and not being able to.
______________________________________________________
______________________________________________________
For Questions D28 - D31, ask client to use the Client’s Rating Scale
______________________________________________________
How troubled or bothered have you been in the past 30 days by
these:
______________________________________________________
D28.
Alcohol problems
___
D29.
Drug problems
___
______________________________________________________
______________________________________________________
How important to you now is treatment for these:
D30.
Alcohol problems
___
D31.
Drug problems
___
CONFIDENCE RATINGS
______________________________________________________
______________________________________________________
Is the above information significantly distorted by:
D34. Client’s misrepresentation?
0 - No
1 - Yes
___
______________________________________________________
D35.
___
______________________________________________________
Client’s inability to understand?
0 - No
1 - Yes
ADAI Sound Data Source—3/2/2007
Page 9
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
ALCOHOL/DRUG USE (cont)
ALCOHOL/DRUG COMMENTS
(Include the question number with your notes)
INTERVIEWER CLIENT NEED RATING
How would you rate this client’s need for treatment for:
______________________________________________________
D99a. Alcohol Abuse
___
D99b. Drug Abuse
___
0-
No alc/drug problems, no need (can include those currently
successfully maintaining abstinence with no tx currently
needed).
______________________________________________________
1-
Alc/drug problems, current tx seems adequate.
______________________________________________________
2-
Need for more tx in addition to current tx.
3-
Urgent need for more alc/drug tx in addition to client’s current (if
any) tx.
ADAI Sound Data Source—3/2/2007
Page 10
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
LEGAL STATUS
L2.
LEGAL COMMENTS
Are you currently on probation or parole?
0 - No
1 - Yes
___
SINCE ENROLLMENT, how many times have you been arrested
and CHARGED with any of the following? (Not necessarily convictions)
L3.
Shoplifting/Vandalism
___ ___
L4.
Parole/Probation Violations
___ ___
L5.
Drug Charges
___ ___
L6.
Forgery
___ ___
L7.
Weapons Offense
___ ___
L8.
Burglary/Larceny/Breaking & Entering
___ ___
L9.
Robbery
___ ___
(Include the question number with your notes)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
L10.
Assault
___ ___
L11.
Arson
___ ___
L12.
Rape/Sexual Assault
___ ___
L13.
Homicide/Manslaughter
___ ___
L14.
Prostitution
___ ___
L15.
Contempt of Court
___ ___
L16.
Other: ___________________________________
___ ___
______________________________________________________
Include only formal charges, not times when client was simply picked up and
questioned.
Code failure to appear as Other and note original charge in comments.
Do not include juvenile charges (<18 yrs) unless she was tried as an adult (but
do note juvenile charges in comments).
______________________________________________________
L17.
How many of these charges resulted in
convictions?
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___ ___
Include charges in L3–L16 above. Do not include charges in L18–L20.
Convictions include fines, probation, suspended sentences, charges for
probation/ parole violations, as well as incarceration.
If L3 through 16=00, then L17=-8
L18.
______________________________________________________
______________________________________________________
______________________________________________________
SINCE ENROLLMENT, how many times have you been charged
with the following:
Disorderly conduct, vagrancy, public intoxication
___ ___
Generally a public annoyance without the commission of a
______________________________________________________
______________________________________________________
particular crime.
L19.
Driving while intoxicated
L20.
Major driving violations
Reckless driving, speeding, no license, etc.
Does not include non-moving violations.
L20a. Since enrollment, how many times have you been
incarcerated?
L21.
How many months were you incarcerated since
enrollment? (total months)
Whether or not charge resulted in a conviction. Includes jail,
detention center, prison.
2 weeks or longer=1 month. <2 wks=000.
L23b. How long was your longest incarceration? (since
enrollment)
Code -8 if never incarcerated.
___ ___
______________________________________________________
___ ___
______________________________________________________
___ ___
______________________________________________________
___ ___ ___
Mos
___ ___
Mos
L24.
Are you presently awaiting charges, trial, or
sentence?
0 - No
1 - Yes
What for?
If multiple charges, code most severe.
Refers to L24. Use codes 3–16, 18–20.
Code -8 if not awaiting charges.
ADAI Sound Data Source—3/2/2007
Page 11
______________________________________________________
___ ___
______________________________________________________
___
______________________________________________________
Do not include civil charges.
L25.
______________________________________________________
______________________________________________________
L23c. What was it for?
Use codes 3–16, 18–20
If multiple charges, code most severe
Code -8 if never incarcerated.
______________________________________________________
___ ___
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
LEGAL STATUS (cont)
L26.
How many days in the past 30 were you detained or
incarcerated?
LEGAL COMMENTS
___ ___
______________________________________________________
Include being detained (e.g., arrested but released on the
same day).
L26a. Is client currently in jail/prison?
0 - No
1 - Yes
Specify: ______________________________
L27.
How many days in the past 30 have you engaged in
illegal activities for profit?
(Include the question number with your notes)
___
______________________________________________________
______________________________________________________
___ ___
______________________________________________________
Drug dealing, prostitution, burglary, selling stolen goods, etc.
NOT simple drug possession or drug use.
Cross-check with E17.
______________________________________________________
For Questions L28 & L29, ask client to use the Client’s Rating Scale
L28.
How serious do you feel your present legal
problems are?
___
______________________________________________________
Do not include civil problems (e.g., custody fights, divorce, etc.).
L29.
How important to you now is counseling or referral
for these legal problems?
______________________________________________________
___
______________________________________________________
Need for additional referral.
______________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
L31.
Client’s misrepresentation?
0 - No
1 - Yes
___
______________________________________________________
L32.
Client’s inability to understand?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
INTERVIEWER CLIENT NEED RATING
L99.
How would you rate the client’s need for legal
services or counseling? (Can include civil
problems)
01-
No legal problems, no need.
Legal problems, but currently receiving adequate services.
2-
Need for more legal assistance than client is currently
connected to.
3-
Urgent need for more legal assistance than client is currently
connected to.
ADAI Sound Data Source—3/2/2007
Page 12
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY/SOCIAL RELATIONSHIPS
FAMILY/SOCIAL COMMENTS
(Include the question number with your notes)
Note: Purpose of this section is to assess inherent relationship
problems, not the extent to which alc/drugs have affected
relationships. Do not include here social/family problems due solely
to client’s substance abuse. In general, ask client: if the alc/drug
problem were absent, would there still be a relationship problem?
F1.
Marital Status
1 - Married
2 - Remarried
3 - Widowed
______________________________________________________
___
4 - Separated
5 - Divorced
6 - Never married
______________________________________________________
Consider common-law (> 7 yrs) as married and specify in comments.
F2.
How long have you been in this marital status?
If never married, since age 18.
F3.
______________________________________________________
__ __ / __ __
Yrs
Are you satisfied with this situation?
0 - No
1 - Indifferent
2 - Yes
Mos
___
Satisfied=client generally likes situation, not simply
resigned to it.
F3a.
______________________________________________________
______________________________________________________
______________________________________________________
How would you describe your current housing
situation?
01 - Permanent/stable (incl. Sec 8 if
______________________________________________________
___ ___
05 - Long-term jail or prison
perm. res.)
______________________________________________________
02 - Transient, emergency shelters
06 - Trans. drug-free housing
03 - Living w/ friend/relative temporarily
07 - Drug/alc tx facility
04 - Homeless (without shelter)
08 - Other (specify below)
Specify other: ________________________________
______________________________________________________
How many times have you moved...
In the past year?
______________________________________________________
F3b.
___ ___
F3c.
Since enrollment?
___ ___
Code 66 if homeless or too many moves to count.
F4.
Usual living arrangements (past 3 years)
01 - With sexual partner & children
02 - With sexual partner alone
03 - With children alone
04 - With parents
05 - With family
___ ___
06 - With friends
07 - Alone
08 - Controlled environment
09 - No stable arrangements
If client lived in several arrangements, choose most representative. If time is
evenly split, choose most recent. Time spent in prisons, institutions, hospitals
is coded 08.
F5.
How long have you lived in these arrangements?
If with parents or family, since age 18.
F6.
__ __ / __ __
Yrs
Are you satisfied with these living arrangements?
Mos
___
(generally likes)
0 - No
1 - Indifferent
Number of children in household (under 18)
___ ___
F4b.
Number of adults in household
___ ___
F7.
Do you live with anyone who:
0 - No
Has a current alcohol problem?
1 - Yes
___
i.e., a drinking alcoholic
Uses non-prescribed drugs?
___
Or abuses prescribed drugs
Whether problematic or not
F7 and F8 do not refer to neighborhood, just who lives in residence with client.
If in treatment or incarcerated, household to which client expects to return.
F9.
With whom do you spend most of your free time:
1 - Family
2 - Friends
3 - Alone
___
F10.
Are you satisfied with spending your free time
this way? (generally likes)
0 - No
1 - Indifferent
2 - Yes
___
How many close friends do you have?
___
Stress that you mean CLOSE.
Does not include family, or boyfriend/girlfriend considered
to be family/spouse.
ADAI Sound Data Source—3/2/2007
Page 13
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
In household/arrangement described in F4:
F11.
______________________________________________________
2 - Yes
F4a.
F8.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY/SOCIAL RELATIONSHIPS (cont)
FAMILY/SOCIAL COMMENTS
F11a. Do you go to church? How active are you?
0 - No, do not go
1 - Yes, but not very active
2 - Yes, but sometimes active
3 - Yes, and very active
___
(Include the question number with your notes)
______________________________________________________
______________________________________________________
Which church? _____________________________
F11b. Have you experienced the death of a family member
or friend since enrollment?
0 - No
3 - Yes, friend
1 - Yes, a child
4 - Yes, other family
2 - Yes, parent
5 - Multiple deaths
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Direction for F12 - F26:
Include biologic and adoptive relatives.
______________________________________________________
0 - Clearly NO for all persons in the category
1 - Clearly YES for any person within category
______________________________________________________
-7 - Uncertain or “I don’t know”
-8 - Never was a person in that category
______________________________________________________
Would you say you have had close, long-lasting, personal
relationships with any of the following people in your life:
______________________________________________________
F12.
Mother
___
F13.
Father
___
F14.
Brothers/Sisters
___
F15.
Sexual Partner/Spouse
___
F16.
Children
___
F17.
Friends
___
A simple yes here is not adequate. Probe to determine if there has been the
ability to feel closeness and mutual responsibility in the relationship. Does
client feel sense of value for the person (beyond simple self-benefit)?
F18.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Have you had a significant period in which you experienced
serious problems getting along with:
Past 30 Days In Your Life
______________________________________________________
Mother
______________________________________________________
___
___
F19.
Father
___
___
F20.
Brothers/Sisters
___
___
F21.
Sexual Partner/Spouse
___
___
F22.
Children
___
___
F23.
Other significant family
___
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Who: _______________________
F24.
Close Friends
___
___
F25.
Neighbors
___
___
F26.
Co-Workers
___
___
Serious problems=those that endanger relationship. “Problem” requires
contact of some sort. If client has had no contact in past 30 days, code -8.
F27.
Did anybody ever abuse you:
0 - No
1 - Yes, once or twice
2 - Yes, repeated times
Past 30 Days In Your Life
As A Child
Emotionally?
___
___
Make you feel bad
___
through harsh words
F28.
Physically?
Cause you physical harm
F29.
___
___
___
ADAI Sound Data Source—3/2/2007
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Sexually?
Force sexual advances
or sexual acts
Page 14
___
______________________________________________________
___
___
MOLESTED
RAPED
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY/SOCIAL RELATIONSHIPS (cont)
FAMILY/SOCIAL COMMENTS
F29a. Are you currently in what you consider to be an
abusive relationship with your partner?
0 - No
3 - Yes, sexual
1 - Yes, physical
4 - Yes, combination
2 - Yes, psychological
___
(Include the question number with your notes)
______________________________________________________
______________________________________________________
How many days in the past 30 have you had serious conflicts:
F30.
with your family?
___ ___
F31.
with other people? (excluding family)
___ ___
______________________________________________________
______________________________________________________
For Questions F32 - F35, ask client to use the Client’s Rating Scale
How troubled or bothered have you been in the past 30 days by
these:
______________________________________________________
______________________________________________________
F32.
Family problems
___
F33.
Social problems
___
______________________________________________________
___
______________________________________________________
How important to you now is treatment or counseling for these:
F34.
Family problems
F35.
Social problems
___
CONFIDENCE RATINGS
Is the above information significantly distorted by:
______________________________________________________
______________________________________________________
F37.
Client’s misrepresentation?
0 - No
1 - Yes
___
F38.
Client’s inability to understand?
0 - No
1 - Yes
___
______________________________________________________
______________________________________________________
INTERVIEWER CLIENT NEED RATING
___
______________________________________________________
0 - No need.
1 - Problems, but client currently connected with adequate services.
______________________________________________________
F99a. How would you rate this client’s need for family and/
or social counseling?
2 - Need for more counseling in addition to client’s current
counseling (if any).
______________________________________________________
3 - Urgent need for more family/social counseling/intervention in
addition to client’s current connection to services.
F99b. How would you rate the client’s need for domestic
violence services?
______________________________________________________
___
______________________________________________________
0 - No domestic violence, no need.
______________________________________________________
1 - Domestic violence problem, but currently stable with services.
2 - Need for more domestic violence services, in addition to client’s
current services (if any).
______________________________________________________
3 - Dangerous domestic violence situation. Urgent need.
ADAI Sound Data Source—3/2/2007
Page 15
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
PSYCHIATRIC STATUS
PSYCHIATRIC STATUS COMMENTS
SINCE ENROLLMENT, how many times have you been treated for
any psychological or emotional problems:
P1.
P2.
In a hospital?
___ ___
As an outpatient or private patient?
___ ___
(Include the question number with your notes)
______________________________________________________
______________________________________________________
Per episode, not # of visits or # of days. Note when/where in comments.
P2a. Have you had a psychiatric evaluation since enrollment?
0 - No
1 - Yes
___
Note reason for evaluation in comments.
______________________________________________________
P2b. If so, evaluation results:
0 - No diagnosis
1 - One diagnosis
2 - More than one diagnosis
-7 - Client doesn’t know her diagnosis
-8 - Client refuses to say, or N/A-hasn’t had an evaluation
P2c. List DSM-IV diagnosis(es) and 3-digit code from manual:
___
______________________________________________________
______________________________________________________
______________________________________________________
If no evaluation, or client had evaluation but no diagnosis, code -8s
Diagnosis 1: ________________________
___ ___ ___
Diagnosis 2: ________________________
___ ___ ___
Diagnosis 3: ________________________
Diagnosis 4: ________________________
___ ___ ___
___ ___ ___
Do not code FAS/FAE diagnosis here, code as Medical Diagnosis in M3.
P3.
______________________________________________________
Do you receive a pension for a psychiatric disability?
0 - No
1 - Yes
___
From whom: ________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Direction for P4-P11:
______________________________________________________
“In your life” refers to the entire lifetime period prior
to the past 30 days. Interviewer: ask lifetime question
from each pair first, then, regardless of answer,
inquire about past 30 days.
Items P4, P5, P6, P7: Be sure symptoms are
psychiatric in nature, i.e., NOT drug related.
______________________________________________________
______________________________________________________
______________________________________________________
P4.
Have you had a significant period (that was not a direct result of
drug/alcohol use) in which you have:
Past 30 Days In Your Life
0 - No
1 - Yes
Experienced serious depression
___
___
Sadness, hopelessness, loss of interest, difficulty
functioning, “crying jags.” (>2 wk period)
P5.
P6.
Experienced trouble understanding,
concentrating or remembering
Serious trouble, suggestive of cognitive problems.
(>2 wk period)
P8.
___
___
______________________________________________________
Experienced hallucinations
“Saw or heard things.” Not related to alc/drugs, can
be flashbacks. (Even once)
P7.
Experienced trouble controlling violent
behavior
___
___
___
___
___
___
___
___
Experienced serious thoughts of suicide
i.e., had a plan; can be drug/alc related. (Even
once)
When last? ________________________
P10. Attempted suicide
Can be drug/alc related. (Even once)
______________________________________________________
______________________________________________________
______________________________________________________
Can be drug/alc related. (Even once)
P9.
______________________________________________________
______________________________________________________
Experienced serious anxiety or tension
Unreasonably worried, unable to relax, feeling
uptight. (>2 wk period)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___
___
___
___
______________________________________________________
When last? ________________________
P11. Been prescribed medication for any
psychological/emotional problem
______________________________________________________
Whether or not she actually took the meds.
ADAI Sound Data Source—3/2/2007
Page 16
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
PSYCHIATRIC STATUS (cont)
PSYCHIATRIC STATUS COMMENTS
P12. How many days in the past 30 have you experienced
these psychological or emotional problems?
___ ___
______________________________________________________
Refers to problems listed in P4-P10.
For Questions P13 & P14, ask client to use the Client’s Rating Scale
P13. How much have you been troubled or bothered by
these psychological or emotional problems in the past
30 days?
(Include the question number with your notes)
______________________________________________________
___
______________________________________________________
Referring to P12.
P14. How important to you now is treatment for these
psychological problems?
___
______________________________________________________
______________________________________________________
The following items are to be completed by the interviewer
At the time of the interview, is client: 0 - No
______________________________________________________
1 - Yes
P15. Obviously depressed/withdrawn
___
P16. Obviously hostile
___
P17. Obviously anxious/nervous
___
P18. Having trouble with reality testing, thought disorders,
paranoid thinking
___
P19. Having trouble comprehending, concentrating,
remembering
___
P20. Having suicidal thoughts
___
P23. Client’s inability to understand?
0 - No
1 - Yes
INTERVIEWER CLIENT NEED RATING
P99. How would you rate this client’s need for psychiatric/
psychological treatment?
______________________________________________________
___
___
___
1 - Psychological problems, but current treatment has brought
condition to a controlled, non-problematic state.
2 - Need for more treatment in addition to client’s current treatment,
but not apparently dangerous or greatly interfering with client’s life.
ADAI Sound Data Source—3/2/2007
Page 17
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
0 - No psychological problems, no need.
3 - Urgent need for more treatment in addition to client’s current
treatment.
______________________________________________________
______________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
P22. Client’s misrepresentation?
0 - No
1 - Yes
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY PLANNING, TARGET CHILD & SUBSEQUENT
BIRTHS
FP1.
Where is target child living now?
1 - With client
3 - Friend
2 - Relative/FOB
4 - Foster Care
5 - Other (specify)___________________________
6 - Target Child deceased
-7 - Mother doesn’t know
-8 - N/A
COMMENTS
(Include the question number with your notes)
___
______________________________________________________
______________________________________________________
PROBE: Is TC living with you now?
FP2.
______________________________________________________
Who has legal custody of TC?
___
Use codes from FP1 above.
Since birth, how many months was target child living with...
______________________________________________________
______________________________________________________
FP3a. Biological mother
___ ___
FP3b. Family member / FOB
___ ___
______________________________________________________
___ ___
______________________________________________________
___ ___
______________________________________________________
___ ___
______________________________________________________
___ ___
______________________________________________________
No state $ involvement
FP3c. Friends / Other
No state $ involvement
FP3d. Relatives (State $)
State $ involvement
FP3e. Foster parents
State $ involvement; include friends if state paid
FP3f. Adoptive parents
Legal adoption
FP3g. Hospital / therapeutic facility
___ ___
FP3a-FP3g should total number of months client was in program
since baby’s birth.
______________________________________________________
FP4a. Does TC have a regular doctor/clinic to go to for
checkups or illnesses?
0 - No
1 - Yes
___
FP4b. Is TC being seen regularly for well-child visits?
0 - No well-child care
3 - Hospital clinic
1 - Private physician
4 - Other (specify below)
2 - Community clinic
___
FP4d. Has TC been seen by a dentist?
0 - No
1 - Yes
2 - Not needed
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Specify other: _________________________________
FP4c. Current status of target child’s immunizations
0 - None
2 - Missing some
1 - Fully immunized
______________________________________________________
___
______________________________________________________
___
______________________________________________________
______________________________________________________
Since birth, target child has had...
FP5a. Number ER visits
___ ___
FP5b. Number serious accidents
___ ___
FP5c. Number serious accidents requiring hospitalization
___ ___
FP5d. Number serious illnesses
___ ___
FP5e. Number serious illnesses requiring hospitalization
___ ___
______________________________________________________
______________________________________________________
______________________________________________________
For FP5a-FP5e, none = 00.
ADAI Sound Data Source—3/2/2007
Page 18
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY PLANNING, TARGET CHILD & SUBSEQUENT
BIRTHS (cont)
FP6.
Does TC have any kind of medical problems that your
doctor is watching and/or has told you about?
Code each; no additional, code 00
COMMENTS
(Include the question number with your notes)
1.___
___
2.___
___
3.___
___
08 - Failure to thrive
00 - None (or no additional)
01 - Respiratory (asthma, freq colds)
09 - Cardiac (heart) problems
02 - Eye problems
10 - Sleep problems (apnea, etc.)
03 - Ear problems, infection
11 - Blood problems (anemia, etc.)
04 - Skin problems (excema, rashes) 12 - Metabolic problems
05 - Allergies
13 - Growth problems
06 - Developmental problems
14 - Genetic disorder (Turner’s, etc.)
07 - Digestive/feeding problems
20 - Other (specify below)
Specify other: ___________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
FP7a. Specify any diagnosis: 0-No diagnosis 1-Diagnosis listed
_____________________________________________
___
______________________________________________________
FP7b. Does TC have FAS or suspected FAS diagnosis?
0 - No
2 - FAE or ARND
1 - FAS
3 - Suspected FAS/FAE
___
______________________________________________________
FP8.
Has TC gone to any special clinic or
received any type of therapy or special
services since he/she was born?
______________________________________________________
1.___
___
3.___
___
2.___
___
4.___
___
Code each; no additional, code 00
00 -No therapy
07 -Therapeutic daycare (e.g., Childhaven)
01 -Physical therapy
08 -Crisis care nursery
02 -Occupational therapy
09 -FAS clinic
03 -Eye doctor
10 -HIV services or clinic
04 -Developmental stimulation prog 11 -Headstart
05 -Cranio-facial clinic (cleft palate, etc.) 12 -Other preschool
06 -High-risk infant follow-up clinic 20 -Other (specify below)
Specify other: ___________________________________
FP9a. Has TC been in babysitting or daycare?
___
0 - No daycare
4 - Home daycare, unlicensed
1 - Licensed center (>30 children)
5 - Friends of family
2 - Licensed center (<30 children)
6 - Relatives
3 - Home daycare, licensed
FP9b. For how many months (total) has TC been in daycare
since birth?
___ ___
FP10a. Who answered Target Child questions?
1 - Bio mom
5 - Foster mom
2 - Bio father
6 - Foster dad
3 - Adoptive mom
7 - Grandmother
4 - Adoptive father
8 - Grandfather
9 - PCAP advocate
10 - Other: ______________________________
___ ___
FP10b. Is respondent familiar with child’s history since birth?
0 - No
1 - Yes
___
FP10c. If no, since what age?
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___ ___
Code in months of age; Not applicable = -8.
ADAI Sound Data Source—3/2/2007
Page 19
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY PLANNING, TARGET CHILD & SUBSEQUENT
BIRTHS (cont)
COMMENTS
(Include the question number with your notes)
Subsequent pregnancies
______________________________________________________
For FP11-FP14: Code # between enrollment and exit.
Do not count target child; None = 0
FP11.
Subsequent pregnancies (#)
___
FP12.
Subsequent terminations (#)
___
FP13.
Subsequent miscarriages (#)
___
Subsequent births (#)
___
FP14.
Include stillbirths.
FP12+FP13+FP14 should total FP11.
FP15.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Is client pregnant now?
0 - No
2 - Yes, deliver but not keep
1 - Yes, plans to keep
3 - Yes, plans to terminate
___
______________________________________________________
______________________________________________________
NOTE: If no subsequent births, code FP16a-FP24 with -8s.
Do not count target child in FP16a-FP24.
FP16a. Date of subsequent birth #1
__ __ /__ __ /__ __ __ __
______________________________________________________
FP16b. Date of subsequent birth #2
__ __ /__ __ /__ __ __ __
______________________________________________________
m m
FP17.
d
d
y
y
y
Outcome of birth(s)
#1 ___
0 - Baby had no problems
1 - Baby required special care, longer stay
2 - Stillbirth, infant death
3 - Other ________________________________
#2 ___
During pregnancy for birth...
#1
#2
Regular prenatal care?
0 - No
1 - Yes
___
___
FP19.
Was pregnancy planned? 0 - No
1 - Yes
___
___
FP20.
Used alcohol/drugs during pregnancy?
0 - No
1 - Yes, occasional alcohol
2 - Yes, heavy alcohol, no drugs
3 - Yes, drugs only
4 - Yes, alcohol & drugs
___
___
Quit using alc/drugs during pregnancy?
___
FP22.
______________________________________________________
______________________________________________________
___
______________________________________________________
0 - No
1 - Yes, for remainder of pregnancy
2 - Abstinent throughout
______________________________________________________
Went into alc/drug tx during pregnancy?
0 - No
1 - Yes, completed
2 - Yes, but dropped tx
___
___
Number of months abstinent during
pregnancy
Child is currently living with...
1 - Client
3 - Friend
2 - Relative/FOB
4 - Foster Care
5 - Legally adopted
6 - Other ___________________________
ADAI Sound Data Source—3/2/2007
______________________________________________________
______________________________________________________
___ ___
___ ___
___ ___
___ ___
Total longest consecutive months
00 - None; 09 - Abstinent throughout
Page 20
______________________________________________________
______________________________________________________
Code -8 if no treatment.
FP24.
______________________________________________________
With or without treatment
FP22a. If so, during what month?
FP23.
______________________________________________________
______________________________________________________
FP18.
FP21.
y
______________________________________________________
______________________________________________________
______________________________________________________
___
___
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
FAMILY PLANNING, TARGET CHILD & SUBSEQUENT
BIRTHS (cont)
FP25.
Including target child, total # of biological children
who live with you now:
COMMENTS
(Include the question number with your notes)
___ ___
FP25a. Including target child, ages of all
biological children who live with you
now:
1. ___ ___
2. ___ ___
3. ___ ___
4. ___ ___
00 = no children or no more children
5. ___ ___
6. ___ ___
FP26.
______________________________________________________
______________________________________________________
Including target child, total # of biological children
who DO NOT live with you now:
___ ___
______________________________________________________
1. ___ ___
2. ___ ___
______________________________________________________
3. ___ ___
4. ___ ___
5. ___ ___
6. ___ ___
00 = no children or no more children
Code from youngest to oldest. Code any infant’s age as 01. If more than 6
children not with mom, list ages of other children here:
_______________________________________________________
FP27a. Since enrollment, has any child been placed into
your custody, moved into the home, and is still
with you?
0 - No
1 - Yes
FP27b. Since enrollment, has any child been removed
from your custody, taken out of the home (even if
later returned)?
0 - No
1 - Yes
How old were you when you had your first
pregnancy?
In years.
FP29.
______________________________________________________
Code from youngest to oldest. Code any infant’s age as 01. If more than 6
children with mom, list ages of other children here:
_______________________________________________________
FP26a. Including target child, ages of all
biological children who DO NOT live
with you now:
FP28.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___
______________________________________________________
___
______________________________________________________
______________________________________________________
___ ___
______________________________________________________
YRS
Do you normally use some method of birth control?
0 - No
1 - Yes, regular use
2 - Yes, sporadic use
FP29a. What method(s) do you use?
01 - Condoms
06 - Abortion
02 - Pills
07 - Abstinence
03 - Norplant
08 - Diaphragm
04 - Depo shot
09 - IUD
05 - Tubal ligation
10 - Other
___
______________________________________________________
______________________________________________________
___ ___
___ ___
___ ___
______________________________________________________
______________________________________________________
______________________________________________________
Other, specify: _________________________
00 = no method or no further method
FP30.
If you use condoms, do you use them every time,
with every sexual partner?
0 - Not every time 1 - Every time
-8 - Never use
___
______________________________________________________
CONFIDENCE RATINGS
______________________________________________________
Is the above information significantly distorted by:
FP31.
Client’s misrepresentation?
0 - No
1 - Yes
___
FP32.
Client’s inability to understand?
0 - No
1 - Yes
___
FP99.
How would you rate the client’s need for family
planning services?
INTERVIEWER CLIENT NEED RATING
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
0-
Uses reliable method regularly or has tubal ligation, no need.
1-
Need for family planning, but currently pregnant.
______________________________________________________
2-
Need for family planning services. Uses birth control, but less
reliable method or practice.
______________________________________________________
3-
Urgent need for family planning.
ADAI Sound Data Source—3/2/2007
Page 21
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
COMMUNITY SERVICES
COMMUNITY SERVICES COMMENTS
Have you used this service during the last year or now?
How is this service working for you? (or your child(ren) or family,
depending on item)
• Code whether or not client or her children, as specified in the item, received this
service during the past year in the “Service Used” column. Code the quality of the
service received in the “Connection with Service” column, using prompts to focus on
how regular or adequate the connection, and her access to service, not on how well
the woman is doing. For example, the connection for AA group would be rated “1Good” if the woman attended regularly, even if she was still drinking.
• If the service was not needed, code -8 in the Service Used and Connection
columns.
S1.
Connection with
Service Codes
1 - Good
2 - Acceptable
3 - Poor
4 - Good/acceptable, but
problem with access
-8 - N/A
A.
Service Used?
B.
Connection With
Service
___
___
___
___
Regular health care provider or clinic for client
Who/Where: _______________________
S1a. Regular health care provider or clinic for child(ren)
S2.
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Direction for S1-S17:
Service Used
Codes
0 - No, but needed
1 - Yes
3 - On waiting list
-8 - Not needed, N/A
(Include the question number with your notes)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Who/Where: _______________________
Other healthcare services - for client
Physical therapy, dentist, eye doctor, etc.
What/Where: ______________________
S2a. Other healthcare services - for child(ren)
Physical therapy, dentist, eye doctor, etc.
___
___
___
___
What/Where: ______________________
______________________________________________________
______________________________________________________
______________________________________________________
#
appropriate
#
inappropriate
S2b. Client
___
___
S2c. Client’s child(ren)
___
___
Emergency Room (E.R.) visits in past year
Code # of visits of each type
If more than 6, code 6
______________________________________________________
______________________________________________________
______________________________________________________
What/Where: ________________________
Appropriate use = true medical emergency. Inappropriate use = healthcare that
should have been provided at a clinic or through a primary care provider.
B.
A.
Connection With
Service Used?
Service
S3.
Family planning, birth control
At clinic, Planned Parenthood, etc.
S4.
S5.
Who/Where: _______________________
Alcoholics Anonymous or Narcotics
Anonymous (or other alcohol/drug peer
support group)
Group/Sponsor: ____________________
Other support group
Social, church group
S6.
What/Where: ______________________
Mental health service (client)
Diagnosis or counseling
___
___
___
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
___
___
___
___
______________________________________________________
______________________________________________________
What/Where: ______________________
ADAI Sound Data Source—3/2/2007
Page 22
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
COMMUNITY SERVICES (cont)
COMMUNITY SERVICES COMMENTS
Have you used this service during the last year or now?
How is this service working for you? (or your child(ren) or family,
depending on item)
Service Used
Codes
0 - No, but needed
1 - Yes
3 - On waiting list
-8 - Not needed, N/A
Connection with
Service Codes
1 - Good
2 - Acceptable
3 - Poor
4 - Good/acceptable, but
problem with access
-8 - N/A
B.
A.
Connection With
Service Used?
Service
S7.
Public housing
Section 8, low income
___
___
___
___
Specify: __________________________
S8.
Emergency housing
Include shelters
Specify: __________________________
S9.
Emergency funds for rent deposits, gas
vouchers, etc. OR Emergency bill
paying service
___
___
Salvation Army, Volunteers of America, etc.
Food Bank
Or other food program, NOT food stamps
___
___
___
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Legal
Court, public defender, prosecutor, probation,
legal clinics. (If client has been in litigation or
resolved charges, warrants, etc., code 1)
______________________________________________________
______________________________________________________
What/Where: ______________________
S12.
______________________________________________________
______________________________________________________
Specify: __________________________
S11.
______________________________________________________
______________________________________________________
Specify: __________________________
Clothing/supplies
______________________________________________________
______________________________________________________
Volunteers of America, St. Vincent, American Red
Cross, Salvation Army, etc. Include special
payment programs offered by utility, phone
companies, etc.
S10.
(Include the question number with your notes)
___
___
______________________________________________________
______________________________________________________
What/Where: ______________________
S13.
______________________________________________________
Domestic violence services
Crisis line, temporary shelter, protection/
restraining orders
___
___
______________________________________________________
What/Where: ______________________
S14.
Public Schools
For extra services or problems, e.g., counseling,
truancy, child behavior issues, etc.
___
___
______________________________________________________
What/Where: ______________________
S15.
Daycare/childcare services
______________________________________________________
___
___
___
___
______________________________________________________
Specify: __________________________
S16.
Public Health Nurse
Home visits
______________________________________________________
Specify: __________________________
S17.
______________________________________________________
Other
YMCA, Boys and Girls Club, Family Support
Center or other community resource center,
Home Builders Program, School Family Support
Worker, Big Brother/Big Sister Program, etc.
___
___
______________________________________________________
______________________________________________________
What/Where: ______________________
ADAI Sound Data Source—3/2/2007
Page 23
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
COMMUNITY SERVICES (cont)
COMMUNITY SERVICES COMMENTS
(Include the question number with your notes)
For questions S19-S24a, code 0 - No, 1 - Yes
S19.
Do you have a private source of medical insurance?
___
Through work, partner’s work, etc.
Specify: ______________________________
______________________________________________________
______________________________________________________
S20.
Are you currently receiving food stamps?
___
S21.
Are you currently enrolled in the WIC program?
___
S22.
Have you had an open case with CPS (Child
Protective Services) since enrollment?
___
______________________________________________________
______________________________________________________
For your own children, not the children of someone else.
S23.
S24.
Do you have an open CPS case now?
___
Have you taken a parenting class since enrollment?
___
At clinic, as part of treatment, co-ops.
S24a. Was this mandated?
___
If S24 is No, then code -8
S24b. Did you complete the course?
0 - No
1 - Completed
2 - In progress
___
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
If S24 is No, then code -8
______________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
S26.
Client’s misrepresentation?
0 - No
1 - Yes
___
S27.
Client’s inability to understand?
0 - No
1 - Yes
___
COMPLETE AFTER CLIENT LEAVES
V1.
Anyone else present during interview?
0 - No
1 - Yes
V2.
Client cooperation
1 - Very uncooperative
2 - Somewhat uncooperative
___
Who? ______________________________
______________________________________________________
COMMENTS ON VALIDITY:
______________________________________________________
______________________________________________________
___
______________________________________________________
3 - Somewhat cooperative
4 - Very cooperative
V3.
Client under influence?
0 - No
1 - Yes, appeared so
2 - May have been, uncertain
___
V4.
Special
1 - Usual, one session interview
2 - Interrupted, multi-session
3 - Client terminated interview
4 - Interviewer terminated interview
___
ADAI Sound Data Source—3/2/2007
Page 24
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Parent-Child Assistance Program (PCAP)
Client #: __ __ __ __ __ __
Date: __ __ / __ __ / __ __ __ __
Interviewer Comments on Interview/Client/Situation
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
PROFILE OF CLIENT NEED BASED ON
INTERVIEWER’S SUBJECTIVE ASSESSMENT
Codes here should match those in interview.
No
Problem/Issue
Problems
0
Problem/Issue
Problem/Issue
Problem/Issue
But currently
stable with
current services
Unaddressed
need, but not
urgent
Has urgent,
immediate
need
Lower priority
High priority
2
3
1
MEDICAL
EMPL/SUPP
ALCOHOL
DRUG
LEGAL
FAM/SOC
DOM VIOL
PSYCH
FAM PLAN
TARGET CHILD
OTHER
Specify Other: _____________________________________________
ADAI Sound Data Source—3/2/2007
Page 25
Parent-Child Assistance Program (PCAP)
| File Type | application/pdf |
| File Title | 8 ASIExit.pub |
| Author | ShradLa |
| File Modified | 2009-07-13 |
| File Created | 2009-07-13 |