Microsoft word - toadsquestionnaire-july-19-05.doc

Tennessee Outcomes for Alcohol and Drug Services (TOADS) Project
Questionnaire (July 2005 Version)
CLIENT - 1ST INTERVIEW - COVER SHEET
A1a: Basic Demographics
A1b: Interview Final Status
_____________________________________________ (2) Client Case #: ______________________________ (3) Date of Admission to Facility: ______/_______/_______ (5) Agency Code ( 5 DIGITS): _______________________ Private Directory _____ Client _____ Collateral Copyright 2005 Institute for Substance Abuse Treatment Evaluation, TOADS Project, The University of Memphis For permission to use parts of or complete questionnaire, please email: Satish Kedia <[email protected]> A1d: Entering into Computer
A1e: Intake Information
(1) Social Security # _________-______-____________ (2) Date of birth (MM/DD/YY) ______/______/______ (3) Date of Intake Interview (MM/DD/YY)_____/_____/_____ 997. Refused 998. Didn’t know 999. No answer/NA 3. Dual diagnosis–both substance abuse & mental health 997. Refused 998. Didn’t know 999. No answer/NA A1f: Basic Demographic Data II
997. Refused 998. Didn’t know 999. No answer/NA
A1g: Summary Information
(3) Where else do you think we might be able to reach you, in six (1) We really appreciate you spending your time talking with us Would it be okay with you if we call you again in next few 1. Gave additional address & phone #. Specify Address:____________________________ __________________________________________ __________________________________________ __________________________________________ (2) Do you expect to be at the same address and phone number, Phone: _________-_________-____________ A1h: For Interviewer Only
(2) What was the mood / attitude of this client /collateral? (1) If the client/collateral terminated the call prior to completion of 4. Irritated: found the questions irritating 5. Harried: too busy to give full attention 6. Suspicious: asked “ Why are you asking that?” 5. Interviewer didn't know. They just hung up without warning 8. Appreciative: grateful to have the chance to tell his/her story 997. Refused 998. Didn’t know 999. No answer/NA 9. Interviewer didn’t know. They just hang up without warning 10. Others, specify______________________ Copyright 2005 Institute for Substance Abuse Treatment Evaluation, TOADS Project, The University of Memphis For permission to use parts of or complete questionnaire, please email: Satish Kedia <[email protected]> Tennessee Outcomes for Alcohol and Drug Services (TOADS) Project
Questionnaire (July 2005 Version)
CLIENT - 1ST INTERVIEW
A1a: Demographic Information
(7) What is the custody status of your children? (1) What is your current marital status? 6. Department of Children’s Services Custody (2) What is your current living arrangement? (8) Are any of your children not in your custody? [Do not ask the client this question. Fill it in based on the last question.] (9) Currently, what is your primary source of financial support or income? [Code primary as ‘1' and mark others as any other 10. With children, other relatives and non-relatives 11. With other relatives and non-relatives 4. Supplemental Security Income (SSI/Welfare) 14. Others, specify___________________________ 6. General estates and trusts (property/inheritance) 7. Interests and dividends (stocks and bonds) 8. Rent received as a landlord 9. Veteran’s payments (3) In the past 30 days, where have you been living most of the 10. Unemployment and workers’ compensation 11. Private and government retirement and disability pensions 1. Shelter (safe havens, TLC, low demand facilities, 2. Street/outdoors (sidewalk, doorway, park, public or 98. No source of income 3. Institution (hospital, nursing home, jail/prison) 4. Housed (own, someone else’s apartment, room, halfway (10) What is your current employment situation? [Mark ‘1' for the primary employment and mark all those that apply as the (4) Do you currently live with someone who uses alcohol 997. Refused 998. Didn’t know 999. No answer/NA (5) Do you currently live with someone who uses drugs? 997. Refused 998. Didn’t know 999. No answer/NA 9. Unable to work at present due to current mental health, developmental or alcohol and drug disorder Copyright 2005 Institute for Substance Abuse Treatment Evaluation, TOADS Project, The University of Memphis For permission to use parts of or complete questionnaire, please email: Satish Kedia <[email protected]> 11. Not seeking employment in the past 30 days (including never employed, volunteer worker, too 17. Other, specify___________________________ 12. Others, Specify___________________________ (12) Which income level best describes what you earned last year? (11) What is your current occupation? [Check all that apply.] 1. Preschool, student, or never employed 997. Refused 998. Didn’t know 999. No answer/NA (13) How many people depend on you for food and shelter? Specify # of persons________________________ 997. Refused 998. Didn’t know 999. No answer/NA 9. Service occupation (except private household workers) 10. Service occupation (private household workers) (14) Are you currently enrolled in school or a job training program? 997. Refused 998. Didn’t know 999. No answer/NA A2b: Treatment
(7) How helpful was your treatment at the facility? 1. Very helpful 2. Somewhat helpful 3. Not helpful at all (1) Did you have to wait for treatment? 997. Refused 998. Didn’t know 999. No answer/NA (8) What did you like the best about this service?_______________ ______________________________________________________ (2) If there was a waiting period, how long did you have to wait to enter treatment? ______________________________________________________ 1. Specify _____Months_____ Weeks_____Days (9) What did you like the least about this service?_______________ ______________________________________________________ (3) Primarily treated for [Check one.] ______________________________________________________ (10) What could have been done to enhance your treatment 7. Alcohol, Drug(s) & Mental Health experience? Specify______________________________________ (11) What kind of special training skills did you receive during (4) How many times have you been treated in last three years for your treatment program? [Check all that apply.] (ex. Assertiveness training, anger management, etc.) (5) Did you complete the entire course of treatment? (ex. Job interview practice, resume writing, etc.) (“How to live in two different cultures”) 5. Other, specify __________________________ 6. Did not receive any special skills training (6) Have you been treated at any other facility since leaving 997. Refused 998. Didn’t know 999. No answer/NA (12) Do you feel that you have performed better at school or work 997. Refused 998. Didn’t know 999. No answer/NA Copyright 2005 Institute for Substance Abuse Treatment Evaluation, TOADS Project, The University of Memphis For permission to use parts of or complete questionnaire, please email: Satish Kedia <[email protected]> A3c: Aftercare Experiences
(9) If you stopped participating, what was the main reason you did (1) Did you participate in aftercare provided by the facility? 1. I was admitted for or continued in further treatment. 5. Other, specify________________________ 997. Refused 998. Didn’t know 999. No answer/NA A4d: Tobacco Use
(3) Since treatment, approximately how many times have you (1) Are you currently using tobacco products of any kind? attended facility-sponsored aftercare activities? 997. Refused 998. Didn’t know 999. No answer/NA 1. Less than once per week (1-3 times in past month) (2) Which tobacco product do you use the most? 3. Several times per week (3-6 times per week) 1. Chewing tobacco/snuff/smokeless tobacco 997. Refused 998. Didn’t know 999. No answer/NA 1. Very helpful 2. Somewhat helpful 3. Not helpful at all A5e: Alcohol Use
(1) On average, how frequently have you used alcohol at this time? (5) If you stopped participating, what was the main reason you did so? 1. I was admitted for or continued further treatment. 1. Less than once per week (1-3 times in past month) 2. I chose not to participate in aftercare (no reason given). 3. Several times per week (3-6 times per week) 5. I was given disciplinary discharge for violating program 997. Refused 998. Didn’t know 999. No answer/NA (2) Have you had any alcohol since treatment? [Do not ask the 8. Other, specify________________________ client this question. Fill it in based on the last question.] 997. Refused 998. Didn’t know 999.No answer/NA (6) Since treatment, have you participated in Alcoholics Anony- mous or Narcotics Anonymous, which is not part of the aftercare (3) For how long you abstained from alcohol? Specify______Months______Weeks______Days 997. Refused 998. Didn’t know 999.No answer/NA A6f: Drug Use
(7) Since treatment, approximately how many times have you 1. Less than once per week (1-3 times in past month) (1) Which drugs have you used since treatment? [Enter only 3. Several times per week (3-6 times per week) illegal drugs here, BUT include alcohol. Always put the first choice of drug on blank 1.If no drug is being used, skip to #5.] Drug/ |Drug/Alcohol Name | Past 30 |Frequency|Route (8) Do you find attending AA or NA helpful? 1. Very helpful 2. Somewhat helpful 3. Not helpful at all 1. _____ | ________________ |_______|________ |_____ 2. _____ |_________________|_______|________ |_____ 3. _____ |_________________|_______|________ |_____ 4. _____ |_________________|_______|________ |_____ 5. _____ |_________________|_______|________ |_____ Copyright 2005 Institute for Substance Abuse Treatment Evaluation, TOADS Project, The University of Memphis For permission to use parts of or complete questionnaire, please email: Satish Kedia <[email protected]> (2) Have you used any drugs since treatment? [Do not ask the client A8h: Arrests
this question. Fill it in based on the last question. Mark ‘1' for only
(1) If you have been arrested since treatment, what were the charges and how many times were you charged? [If no arrests, skip 997. Refused 998. Didn’t know 999. No answer/NA (3) Have you used both alcohol and drugs since treatment? [Do 1. __________________________|_________________ not ask the client this question. Fill it in based on question 1.] 2. __________________________|_________________ 3. __________________________|_________________ 4. __________________________|_________________ (4) How long after treatment did you start taking alcohol or drugs 5. __________________________|_________________ Specify______Months______Weeks______Days (2) Have you been arrested since treatment? [Do not ask the client this question. Fill it in based on last question.] (5) If you abstained from drugs, how long have you been Specify______Months______Weeks______Days (3) Was it for alcohol or drugs? [Do not ask the client this question. Fill it in based on question 1.] (6) Has anyone else in your family abused alcohol or drugs in the (4) How many times since treatment have you been arrested for alcohol or drug related offenses? [Do not ask the client this question. Fill it in based on question 1.] (7) If yes, who in your family has abused alcohol or drugs? 1. Specify_________________________________ (5) How many times since treatment have you been arrested for driving under the influence? [Do not ask the client this question. Fill it in based on question 1.] Specify___________________________________ (6) How many days or weeks have you been in jail since your A7g: Relapse Information
1. Specify______Months______Weeks______Days (1) Was there anything that happened since treatment that 997. Refused 998. Didn’t know 999. No answer/NA (7) Are you presently awaiting charges, trail or sentencing? 1. Specify_______________________________________ (2) If employed, how many times have you missed work because of alcohol or drug problems in the last 30 days? 1. Specify_______________________________________ (9) Do you have a valid driver’s license? (10) Have you had your driver’s license revoked for Driving Under Copyright 2005 Institute for Substance Abuse Treatment Evaluation, TOADS Project, The University of Memphis For permission to use parts of or complete questionnaire, please email: Satish Kedia <[email protected]> (11) Did you commit domestic violence before your treatment? (4) Since treatment, do you have better(physical) health? 997. Refused 998. Didn’t know 999. No answer/NA 997. Refused 998. Didn’t know 999. No answer/NA (12) Have you committed domestic violence since your treatment? (5) How do you rate your overall health right now? 997. Refused 998. Didn’t know 999. No answer/NA 997. Refused 998. Didn’t know 999. No answer/NA (13) Were you the victim of domestic violence before your (6) Have you experienced any of the following in the last 30 997. Refused 998. Didn’t know 999. No answer/NA 2. Experienced serious anxiety or tension (14) Have you been the victim of domestic violence since 4. Experienced trouble understanding, concentrating or 997. Refused 998. Didn’t know 999. No answer/NA 5. Experienced trouble controlling violent behavior 6. Experienced serious thought of suicide A9i: Pregnancy (For Females Only)
8. Been prescribed medication for any psychological/ (1) Are you pregnant/expecting at this time? 997. Refused 998. Didn’t know 999. No answer/NA 997. Refused 998. Didn’t know 999. No answer/NA (2) If yes, are you currently receiving prenatal care? (7) In last six months, how many times have you been treated 997. Refused 998. Didn’t know 999. No answer/NA 1. Emergency Room ______ | _____ | ______ 2. Inpatient Care/Hospital ______ | _____ | ______ A10j: Physical/Mental Health
3. Outpatient Care ______ | _____ | ______ [Ask questions 1-3 only if the client has relapsed. If the client did 997. Refused 998. Didn’t know 999. No answer/NA (1) During the past 30 days, have you encountered any stress due to the use of alcohol or other drugs? 997. Refused 998. Didn’t know 999. No answer/NA (2) During the past 30 days, has the use of alcohol or drugs caused you to reduce or give up important activities? 1. Not at all 997. Refused 998. Didn’t know 999. No answer/NA (3) During the past 30 days, has the use of alcohol or drugs caused you to have emotional problems? 1. Not at all 997. Refused 998. Didn’t know 999. No answer/NA Copyright 2005 Institute for Substance Abuse Treatment Evaluation, TOADS Project, The University of Memphis For permission to use parts of or complete questionnaire, please email: Satish Kedia <[email protected]>
Status Codes
Codes for the Reasons for Arrest
Major driving violations (reckless driving, speeding, Number not in service / changed to non-published / will not Insufficient information given by facility 11 Signed up but no treatment / less than two days treatment 17 Disorderly conduct, vagrancy, public intoxication 19 Partially complete interview 20 Complete Route of A dministration
Frequency of Use
Copyright 2005 Institute for Substance Abuse Treatment Evaluation, TOADS Project, The University of Memphis For permission to use parts of or complete questionnaire, please email: Satish Kedia <[email protected]> Drug Class with Street Names
Opiates: Heroin (H, dope, skag, smack, junk), Methadone, Morphine (M, monkey, white stuff, Roxanol,
Duramorph), Opium (hop, big O, gum, block), Fentanyl (Apache, China white, China girl, Sublimaze), Codeine
(Captain Cody, ingredient in certain cough syrups), OxyContin (Oxy, Killer), Demerol, Vicodin, Dilaudid, Darvon
Alcohol: Beer, Wine, Liquor, Booze, Juice, Brew, Vino, Sauce
Barbiturates: Amytal, Nembutal, Seconal, Phenobarbital, Barbs, Downers, Phennies, Reds, Tooies, Yellows,
Yellow Jackets
Other Sedatives or Hypnotics: Methaqualone (Quaalude, Ludes), Chloral Hydrate (Noctec), Doriden, Miltown,
Equanil
Amphetamines: Dexedrine, Biphetamine, Bennies, Speed, Uppers
Cocaine: Coke, Crack, Blow, Snow, Bump, C, Dust
Marijuana/Hashish: Pot, Chronic, Hash, Dope, Blunt, Joints, Reefer, Weed, Grass, THC, Gangster
Hallucinogens: LSD (Acid, Blotter, Boomers, Cubes), PMA, DOB (STP), peyote (mescaline, buttons), DMT, psychedelic
mushrooms (mushrooms, shrooms, cubes, “magic” mushrooms)
Inhalants: Gasoline, paint thinner, spray paint, art and office supply products (felt-tip markers, correction fluid, white-out),
whipped cream dispensers (whippets, poppers, snappers), ether, glue, chloroform, nitrous oxide (laughing gas),
butane, propane, aerosols, any nitrites
Over-the-Counter Medications: Cough syrup, over-the-counter sleeping pills (i.e., Sominex), No-Doz, nasal spray, etc.
Tranquilizers: Includes benzodiazepines, Ativan, Valium, Xanax, Librium, Halcion, downers, sleeping pills, candy
Methamphetamine: Meth, Speed, Crystal, Crystal Meth, Crank, Chalk, Ice, Glass
Other Stimulants: Nicotine (cigarettes, cigars, pipes, snuff, spit tobacco, chew), Ritalin (the smart drug, Vitamin R)
PCP (phencyclidine): Angel Dust, Ozone, Wack, Rocket Fuel
Club Drugs (*note: These drugs are sometimes defined as “other.”): Ecstasy (MDMA, X, XTC, “hug” drug,
love drug, roll, beans), GHB (battery acid, Grievous Bodily Harm, Georgia Home Boy, liquid X, liquid G), Ketamine
(Special K, Vitamin K, K), and Rohypnol (date rape drug, Ruffies, Rope, Rophies)
18 Others
Copyright 2005 Institute for Substance Abuse Treatment Evaluation, TOADS Project, The University of Memphis For permission to use parts of or complete questionnaire, please email: Satish Kedia <[email protected]>

Source: http://www.isate.memphis.edu/Instruments/TOADSQuestionnaire-July-19-05.pdf