18-Month Client-Le 18-Month Client-Level Abstraction Tool

Substance Abuse Mental Health Services Administration

18-Month Client Level Abstraction Tool

OMB No: XXXXX

Expiration Date: XXXX

Public Burden Statement: 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 XXXX-XXXX.  Public reporting burden for this collection of information is estimated to average 10 minutes per respondent, 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 2-1057, Rockville, Maryland, 20857.

Community Support Evaluation: BHTCC

18-month Client-level abstraction tool

Client ID |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|

Note: This is the same Client ID used for Common Data Platform reporting.

Contract/Grant ID |____|____|____|____|____|____|____|____|____|____|

_____________________________________________________________________________________

NOTE: THE FOLLOWING ITEMS ARE TO BE ABSTRACTED FROM EXISTING SYSTEMS AND ENTERED INTO THE 18-MONTH ABSTRACTION TOOL IN EXCEL.

RECIDIVISM

1. Enter the number of times and corresponding dates that the client has been rearrested since baseline/intake [from the NCIC database].

|____|____| times (IF NONE, ENTER ZERO)  

1.a. Date of 1^st arrest (mm/dd/yy)

|____|____| ____| 

1.b. Date of 2^nd arrest  

|____|____| ____| 

1.c. Date of 3^rd arrest

|____|____| ____| 

1.d. Date of 4^th arrest  

|____|____| ____| 

1.e. Date of 5^th arrest

|____|____| ____| 

1.f. Date of 6^th arrest  

|____|____| ____| 

1.g. Date of 7^th arrest

|____|____| ____| 

1.h. Date of 8^th arrest  

|____|____| ____| 

2. Enter the number of times and corresponding dates that the client has been recommitted since baseline/intake [to the state department of corrections].

|____|____| times (IF NONE, ENTER ZERO)  

2.a. Date of 1^st recommitment (mm/dd/yy)

|____|____| ____| 

2.b. Date of 2^nd recommitment   

|____|____| ____| 

2c. Date of 3^rd recommitment

|____|____| ____| 

2.d. Date of 4^th recommitment   

|____|____| ____| 

2.e. Date of 5^th recommitment

|____|____| ____| 

2.f. Date of 6^th recommitment   

|____|____| ____| 

2.g. Date of 7^th recommitment

|____|____| ____| 

2.h. Date of 8^th recommitment   

|____|____| ____| 

3. Enter the number of revocations and corresponding dates (violations of probation/parole) since baseline/intake.

|____|____| times (IF NONE, ENTER ZERO)  

3.a. Date of 1^st revocation (mm/dd/yy)

|____|____| ____| 

3.b. Date of 2^nd revocation   

|____|____| ____| 

3.c. Date of 3^rd revocation

|____|____| ____| 

3.d. Date of 4^th revocation   

|____|____| ____| 

3.e. Date of 5^th revocation

|____|____| ____| 

3.f. Date of 6^th revocation   

|____|____| ____| 

3.g. Date of 7^th revocation

|____|____| ____| 

3.h. Date of 8^th revocation   

|____|____| ____| 

RISK ASSESSMENT DATA

4. Enter the baseline criminogenic risk assessment score (Note: each program will provide the name of the tool used for assessment)

|____|____| ____|

� No score available

4.a. Select the name of the risk assessment the score is based on:

[INCLUDE DROP DOWN LIST OF RISK ASSESSMENT TOOLS]

5. Age at first offense (arrest): ______

6. Number of prior arrests (prior to baseline): _____

5