GPRA Assessments 

Government Performance and Results Act (GPRA) Assessments General Overview

The Government Performance and Results Act (GPRA) assessment is used to evaluate the performance of HHSC substance use programs. The programs that use this assessment include, but are not limited to, the programs which receive funding originating from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT)

General Information about all GPRA Assessment Types

An assessment, more comprehensive than a screening, is a health professional’s review of an individual. The review consists of an evaluation of a variety of domains including current and past functioning in the areas of Demographics, Planned Services, Living Conditions, Education Employment and Income, Legal, Mental and Physical Health, Social Connectedness, Follow Up Status, Discharge Status and Services Received for and Treatment/Recovery Providers.

The assessment is the foundation for collaboration with the client on the development of the plan for treatment and recovery. 

How to conduct a GPRA Assessment

GPRA Assessments are in addition to existing assessments and data collection tools within CMBHS system.

Assessments must be conducted in person unless your organization has been instructed otherwise.

Before You Start an Assessment

Your business entity must have a contract (or other approved written agreement) with HHSC to perform GPRA Assessments and document them in CMBHS.

The CMBHS user must be assigned a role that permits documentation of GPRA Assessments. You must have the proper credentials and they must be accurately entered into your CMBHS account to be assigned those roles. Click here for a summary of Roles in CMBHS and each role's Read-Only or Read/Write Page Rights.

Some CMBHS roles permit a user to document assessments, but they cannot put the assessment in Closed Complete status. Because of their limited credentials, they may only place the assessment in Ready for Review status. It must then be signed off by a clinician who can put the assessment in Closed Complete status.

Before you attempt to document an Assessment in CMBHS, make sure you are fully aware of how to use the Document Status and Save functions. Knowing how to use these functions will reduce the likelihood of losing information or making errors that cannot be corrected. For more information about Document Status, Click here.

Verify that you have the correct client record by checking the client’s name and at least one other identifier before you begin to document.

To begin a GPRA assessment, your agency and the client must meet the following pre-conditions:

Initial GPRA Assessment

Pre-Conditions for Treatment Clients:

Clients in treatment services must have the following three documents in place:

1. The client must have an admission.
2. The client must have a financial eligibility with DSHS Program Funding or BMO Authorized Funding. Financial Eligibility can be completed within the same provider, or it can be consented from OSAR Provider Location.
3. The client must have a Service Begin, in closed complete status, with a one of the Service Type as mentioned following.

• Opioid Substitution Therapy (Medication Assisted Therapy - Re-bundled) - Adult
• Opioid Substitution Therapy (Medication Assisted Therapy) - Adult
• Opioid Treatment Services (Bundled)- Adult
• Office Based Opioid Treatment - Adult
• Office Based Opioid Treatment - Specialized Female - Adult

 

• The funding source for these service types must be DSHS Program Funding or BMO Authorized Funding. 
• The service begin must have been created within the same Provider/ Administrative Location, however, it is allowable for the service begin to have been created at a different Service/Clinic location. The secondary location must still meet the location-based requirements for accessing GPRA.

3. The client must have an Initial SUD Assessment in closed complete status. 

• The document type must be “Assessment SUD” with the description containing the phrase “Initial-Treatment Services” 
• Clients who begin in detoxification service types, or other mental health services may have a different initial assessment type and subsequently only had an “Update” SUD assessment when they began MAT services. In this instance you must go back and do an initial SUD Assessment.  

Pre-Conditions for Recovery Support Services/ Case Management Clients:

• The client must have an Open Case with the case type: “TTOR-Recovery Services – Youth” or “TTOR - Recovery Services – Adult” or “TTOR Integrated Services”.

Six Month Follow-Up GPRA Assessment

• You will be able to initiate the Follow-up assessment only when an initial assessment is in "Closed Complete" status, and it has been at least 5 months since the initial GPRA assessment interview date.
• If the initial GPRA Assessment is in “Ready for Review" and/or "Draft" statuses, then the system will display the pop-up message to inform a user about the missing information.

 

 

Discharge:

• The discharge GPRA assessment will be available in the Treatment location (only if service offered for Opioid is "yes") and in the Recovery Support Services location- Adult and for Youth (for TTOR participant)
• The user will be able to initiate the discharge assessment only when the initial assessment is in the "Closed Complete" status.
•  If the initial GPRA Assessment is in “Ready for Review" and/or "Draft" statuses, then the system will display the pop-up message to inform a user about the missing information.
•  You can access the discharge assessment using the menu on the left of the screen or, for treatment clients, you may access the assessment within the Discharge Client document. When accessing through the Discharge Client document type, you should fill out the required fields prior to initiating the GPRA Discharge Assessment.

Time Frame for GPRA Assessment Completion

CMBHS sends reminder messages to remind staff when each GPRA Assessment type is due. The messages will only be sent to the clinician/recovery coach/case manager assigned to the client. Reminder messages will not display in your clinician/recovery coach/case manager workspace for clients who are unassigned. To see if the client needs an assessment completed you may view reminders in the Client Workspace or use the “GPRA – Clients Due for Assessment” report. More details click here.

Initial For clients in Medication Assisted Treatment (Opioid Treatment Services or Office Based Opioid Treatment) programs except services like Opioid Therapy Services (NAS) – Adult” and “Opioid Substitution Therapy (MAT Specialized Female) (PPW) – Adult, GPRA initial assessments should be completed within 4 days after the client enters the program, but no later than 4 weeks after their Service Begin date.  For clients in Recovery Support Services (RSS) programs, GPRA initial assessments should be given when a client is fully engaged in RSS services. This includes when a client commits to long term recovery coaching. If a client is engaged in services 60 days after their Case Open date, the program should conduct a GPRA assessment. An initial GPRA assessment is completed when a client begins services for the first time. Each time a client leaves treatment/recovery support services and their file is closed, but they reenter treatment at a later date, an additional round of GPRA assessments must be initiated using the initial identifier assigned to the client. Changes in the federal funding may also require completing a new initial GPRA assessment. The dates for follow-up assessments will be determined by the date of the most recent initial GPRA assessment. For example: A client enters in January and completes the first GPRA intake assessment. He/she leaves treatment in March and his/her file is closed. He/she re-enters treatment in April and completes the second GPRA intake assessment. The client’s first 6-month follow-up assessment will be due in October (6 months after April). Six Month Follow-Up Follow-up assessments should be completed by the sixth month from the GPRA initial assessment date.  The window period allowed for these GPRA follow-up assessments is one month before the 6-month anniversary date and up to two months after the 6-month anniversary date. For example, if a client receives the GPRA initial assessment on January 1st, the six-month follow-up anniversary date would be July 1st.  The window period for conducting the 6-month follow-up assessment would open one month before the anniversary date on June 1st, and close two months after the anniversary date on September 1st. The target follow-up rate is 100%; meaning programs must attempt to follow-up with all clients. The minimum follow-up completion rate is 80%.   Discharge When to conduct the GPRA discharge assessment? If the client is present on the day of discharge/closing their case, the GPRA discharge assessment should be conducted on the day of discharge. If a client has not finished treatment, drops out, or is not present the day of discharge/closing their case, the program must locate the client to conduct the in-person assessment.  Your organization will have 14 days after discharge to contact the client and conduct the in-person discharge assessment.  If the assessment has not been conducted by day 15, conduct an administrative discharge.  For an administrative discharge when the assessment is not conducted, you must complete the Record Management tab, Discharge Status tab, and Services Received tab and mark that the interview was not completed.  CMBHS will navigate you through the correct skip patterns, or if completing using the printed blank forms, follow the skip pattern instructions on the tool.

 

Record Management Information

OVERVIEW

This section pertains to client identification information. The Record management information must be filled out for each GPRA assessment. This section is filled out by you while conducting the assessment; the questions are not asked of the client.

 

1. GPRA Document Number (System Generated)

 

This is a unique number assigned to each document in a sequential order.

 

2. CMBHS Client ID (System Generated)

 

This field automatically fills in the client’s CMBHS client ID. The ID is used when reporting to federal systems.

 

3. Client Description By Grant Type  (System Generated)

       Intent/Key Points

       This question identifies the type of services the client is receiving.

       Answer Choice Definitions

       There are two types of clients included in this categorization:

• Treatment client—A client who is receiving substance use treatment by your agency.
• Client in recovery—A client who is receiving recovery support services from your agency.

    Notes

• If the patient is in SUD treatment services and has a Service Begin with an eligible Service-Type of "Opioid" then CMBHS will display "Treatment client". You must be entering this record while under a CMBHS location that provides treatment services.
• If the patient is in Recovery Support Services and has an Open Case with Case Type "TTOR - Recovery Services - Adult", or “TTOR -Recovery – Youth” or “TTOR Integrated Services” then CMBHS will display "Client in recovery". You must be entering this record while under a CMBHS location that provides recovery support services.   ‎ 

 

4. Interview Type (Required)

 Intent/Key Points

It is the type of GPRA assessment that is being completed.

For each interview, CMBHS will automatically fill in the assessment type based on the link you used to start the assessment.

Initial GPRA Assessment

Answer Choice Definitions

• No selections are required. The system will automatically record that you are completing an initial assessment.
• For an initial assessment you will enter the interview date.

6-month follow up GPRA Assessment

Answer Choice Definitions

• No selections are required. The system will automatically record that you are completing 6-month follow up assessment.
• For follow-up GPRA Assessment, you will indicate whether the interview was conducted, and if conducted, enter the interview date.

Did you conduct the interview?  has two option sets: Yes OR No

If No is selected, a new field displays, ‘How many attempts were made to contact this client for the interview? (Required): A number must be entered.

• CLICK the radio button option that best matches the client’s answer:
  • “YES” — Select this when you can conduct the assessment with the client.
  • “NO” – Select this when you are not able to conduct the assessment with the client. In the Follow-up status tab, you will be able to select the reason why the follow-up assessment could not be conducted.   

Discharge GPRA Assessment

• No selections are required. The system will automatically record that you are completing Discharge assessment.
• For Discharge GPRA Assessment, you will indicate whether the interview was conducted, and if conducted, enter the interview date.

     Did you conduct the interview?  has two option sets: Yes OR No

If No is selected, a new field displays, ‘How many attempts were made to contact this client for the discharge interview? (Required) : A number must be entered.

• CLICK the radio button option that best matches the client’s answer:
  • “YES” — Select this when you can conduct the assessment with the client.
  • “NO” – Select this when you are not able to conduct the assessment with the client.

Notes

• When “NO” is selected, the system will automatically hide the assessment tabs that are not required. 

• For Follow-up GPRA Assessment Only
  • An Initial GPRA Assessment must exist. 
  • The Initial GPRA Assessment date must be at least 5 months prior to the time a Follow-up GPRA Assessment is conducted.
• For Discharge GPRA Assessment Only
  • An Initial GPRA Assessment must exist. 
  • Discharge assessment date must be after the initial GPRA assessment date.

5. Interview Date (Required)

Intent/Key Points

The date the GPRA assessment was completed. (If an interview was not conducted for follow-up or discharge, this question will not appear.)

The initial GPRA interview date will determine when subsequent follow-up interviews are due. It is also used to calculate the project’s follow-up rate based on how many of the follow-up interviews that were due that have been completed. The GPRA intake/baseline interview date combined with the discharge date is used to calculate the client’s length of stay.

Notes

The interview date is auto populated by the system with the current/today's date.

The Interview Date cannot be future dated.

For Treatment Clients

Initial 'Interview Date' cannot be greater than 90 days in the past. If the user attempts to backdate the 'Interview Date' more than 90 days, the system will not allow the user and will display an error message: "Interview date cannot be more than 90 days in the past."

Interview Date cannot be prior to the Service Begin Date (Service Begin Document capture eligible 'Opioid' service that needs GPRA Assessment to be documented for the client). If the user tries attempts to backdate prior to Service Begin Date, then the system must display an error pop up 

Error Message: Interview Date cannot be before the start date of state funded services on the Service Begin (DSHS Program Funding or BMO Authorized Funding)

For RSS Clients or Case Management Clients

• Interview Date cannot be prior to Open Case Date.  if Interview Date is prior to the open case date upon saving the document, then the system will display the following warning message: "Interview Date cannot be before the Open Case Date".
• The user can backdate up to 90 calendar days. But it should not be before the open case date.  
• You will not be allowed to continue if the date is blank. The following warning message will appear: "Interview Date is required".

 

Demographics

Intent/Key Points

Demographics Tab is only applicable to ‘Initial GPRA Assessment’.

1a. What is your birth month?  (Optional)

1b. What is your birth year? (Optional)

Check here if the client REFUSED to provide their birth month and year. (Optional)

Answer Choice Definitio

a. The ‘Birth Month’ data field has a drop-down function. The drop-down displays all the months in a year. Selection of Birth Month is an optional field to save the document.

b. The ‘Birth Year’ has numeric text box function where the selection is restricted to a maximum year of current year minus 10.

c. System will pre-populate ‘Birth Month’ and ‘Birth Year’ when the form is initially uploaded from Client Services Toolbar menu. You can clear out the birth details what was pulled onto the GPRA Form and make edits to pre-populated data, in case, corrections are needed. And, update the Client Profile.

d. If Client does not wish to provide Birth Details, then Select ‘REFUSED’ check box. CLICKING on REFUSED will HIDE Birth Month AND BIRTH YEAR questions.

2. What do you consider yourself to be? (Optional)

    Intent/Key Points

    The intent of this question is to determine Biological Sex details of the client.

    It is an optional question.

    Answer Choice Definitions

    CLICK the radio button option that best matches the client’s answer:

• Male
• Female
• Transgender (Male to Female)
• Transgender (Female to Male)
• Biological Sex non-conforming
• Other (Specify)
• REFUSED

If ‘Other (Specify)’ is selected as an option set, then, system displays an additional field ‘Other (Specify Biological Sex)’ with a control type of numeric text box. And it is a required text box to save the document in the system.

3. Are you Hispanic, Latino/a, or of Spanish origin? (Optional)

Intent/Key Points

The intent of this question is to determine Ethnicity details of the client.

Answer Choice Definitions

 CLICK the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

CLICKING ON ‘YES’ will result to an additional question as following.

3a.   [IF YES] What ethnic group do you consider yourself? You may indicate more than one. (Optional)

It is an optional question.

 Answer Choice Definitions

 CLICK the check box options that best matches the client’s answer:

• Central American
• Cuban
• Dominican
• Mexican
• Puerto Rican
• South American
• Other (Specify)
• Refused

a. CLICKING on ‘REFUSED’ will grey out all the ‘Ethnicity’ option sets including ‘Other (Specify)’.

b. If ‘Ethnicity’ option set is selected or Other (Specify) is selected, then ‘REFUSED’ would not be able to select.

c. You can multi-select Ethnicities option sets including ‘Other (Specify)’.

d. If ‘Other (Specify)’ check box is selected, then system displays a numeric text box in data field ‘Other (Specify Ethnic Group) And it is a required text box to save the document in the system.

 

4. What is your race? You may indicate more than one. (Optional)

Intent/Key Points

  The intent of this question is to determine RACE details of the client.

Answer Choice Definitions

 CLICK the check box option that best matches the client’s answer:

• Black or African American
• White
• American Indian
• Alaska Native
• Asian Indian
• Chinese
• Filipino
• Japanese
• Korean
• Vietnamese
• Other Asian
• Native Hawaiian
• Guamanian or Chamorro
• Samoan
• Other Pacific Islander
• Other (Specify)
• Refused

NOTES

a. CLICKING on ‘REFUSED’ will grey out all the ‘RACE’ option sets including ‘Other (Specify)’.

b. If ‘RACE’ option set is selected or Other (Specify) is selected, then ‘REFUSED’ would not be able to select.

c. You can multi-select RACE option sets including ‘Other (Specify)’.

d. If ‘Other (Specify)’ check box is selected, then system displays a numeric text box with a field name ‘Other (Specify Race)’. And it is a required text box to save the document in the system.

 

5. Do you speak a language other than English at home? (Optional)

Intent/Key Points

The intent of ths question is to determine whether the client speaks other language other than English at home.

It is an optional question.

Answer Choice Definitions

CLICK the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

IF ‘YES’ is selected as a response on the above-mentioned question, then the system displays an additional question as following.

5a. [IF YES] What is this language? (Optional)

Intent/Key Points

The intent of this question is to determine whether the client speaks other language other than English at home.

It is an optional question.

Answer Choice Definitions

CLICK the radio button option that best matches the client’s answer:

• Spanish
• Other
• Refused

 

If ‘Other’ is selected, then system displays a numeric text box to enter details. It is a required numeric text box.

6. Do you think of yourself as ...[YOU MAY INDICATE MORE THAN ONE] (Optional)

 

 

Intent/Key Points

The intent of this question is to determine SEXIDENT details of the client.

It is an optional question.

Answer Choice Definitions

CLICK the check box option that best matches the client’s answer:

• Straight or Heterosexual
• Homosexual (Gay or Lesbian)
• Bisexual
• Queer, Pansexual, And/Or Questioning 
• Asexual
• Other 
• Refused

NOTES

a. CLICKING on ‘REFUSED’ will grey out all the ‘SEXIDENT’ option sets including ‘Other (Specify)’.

b. If ‘SEXIDENT’ option set is selected or Other (Specify) is selected, then ‘REFUSED’ would not be able to select.

c. You can multi-select SEXIDENT option sets including ‘Other (Specify)’.

d. If ‘Other (Specify)’ check box is selected, then system displays a numeric text box with a field name ‘Other (Specify Sexual Identity). And it is a required text box to save the document in the system.

7. What is your relationship status? (Optional)  

 

 Intent/Key Points

 The intent of this question is to determine Relationship Status details of the client.

 Answer Choice Definitions

 CLICK the radio button option that best matches the client’s answer:

• Married
• Single
• Divorced
• Separated
• Widowed
• In a relationship
• In multiple relationships
• Refused 

8. Are you currently pregnant? (Optional)

 

Intent/Key Points

The intent of this question is to determine pregnancy details of the client.

Answer Choice Definitions

CLICK the radio button option that best matches the client’s answer:

• Yes
• No
• Do not know
• REFUSED

9. Do you have children? [Refers to children both living and/or who may have died] (Optional)

Intent/Key Points

The intent of this question is to determine children details of the client. 

Answer Choice Definitions

CLICK the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

IF ‘YES’ is selected as a response in the above-mentioned question, then the system will display following question.

9a. [IF YES] How many children under the age of 18 do you have? (Optional)

 Intent/Key Points

The intent of this question is to determine children details of the client.

 Answer Choice Definitions

This question provides an entry box to enter the numeric number. Number entered should be in the range 0-99.

If number greater than 0 is entered in this question, then an additional will be displayed as following.

9b.       Are any of your children, who are under the age of 18, living with someone else due to a court's intervention? [THE VALUE IN ITEM 9b CANNOT EXCEED THE VALUE IN 9a.] (Optional)

Intent/Key Points

The intent of this question is to determine children details of the client.                

Answer Choice Definitions

 CLICK the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

 

IF ‘YES’ is selected as a response in the above-mentioned question, then the system will display following question.

If yes, what is the number of children removed from client’s care? (Optional)

Answer Choice Definitions

This question provides an entry box to enter the numeric number. Number entered should be in the range 0-99.

Number entered in this question must not exceed the value in question 9a.

If number greater than 0 is entered in this question, then an additional will be displayed as following.

9c.       Have you been reunited with any of your children, under the age of 18, who have been                previously removed from your care? [THE VALUE IN ITEM 9c CANNOT EXCEED THE VALUE IN 9a]. (Optional)           

Answer Choice Definitions

CLICK the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

 

IF ‘YES’ is selected as a response in the above-mentioned question, then the system will display following question.

If yes, what is the number of children with whom the client has been reunited? (Optional)

Answer Choice Definitions

This question provides an entry box to enter the numeric number. Number entered should be in the range 0-99.            

Number entered in this question must not exceed the value in question 9a.

10.  Have you ever served in the Armed Forces, in the Reserves, in the National Guard, or in other Uniformed Services? [IF SERVED] What area, the Armed Forces, Reserves, National Guard, or other did you serve? (Optional)

 

Intent/Key Points

The intent of this question is to determine Military, Armed Forces and National Details of the client.

Answer Choice Definitions

CLICK the radio button option that best matches the client’s answer:

• No
• Yes, In the Armed Forces
• Yes, In the Reserves
• Yes, In the National Guard
• Yes, Other Uniformed Services [Includes NOAA, USPHS]
• Refused

11. How long does it take you, on average, to travel to the location where you receive services provided by this grant? (Optional)  

Intent/Key Points

The intent of this question is to determine Military, Armed Forces and National Details of the client.   

Answer Choice Definitions          

CLICK the radio button option that best matches the client’s answer:

• Half an hour or less
• Between half an hour and one hour
• Between one hour and one and a half hours
• Between one and a half hours and two hours
• Two hours or more
• REFUSED

Substance Use Tab 

1. Using the table below, please indicate the following:

A. The number of days, in the past 30 days, that the client reports using a substance.

 

 

[DO NOT READ TO CLIENT] The client should be encouraged to list the substances on their own. If they are unsure, the list of the table below can be read to the client. Please note that not all substance use is considered harmful or illicit – it may be that a substance is prescribed by a licensed provider, or that the client uses the substance in accordance with official, national safety guidelines. In such instances, clarification from the client should be sought, but if the substance is only taken as prescribed or used on each occasion in accordance with official, national safety guidelines, then it is not considered misuse. If no use of a listed substance is reported, please enter a zero (‘0’) in the corresponding ‘Number of Days Used’ column. If the client refuses to answer the question, then select "REFUSED".  

B. The route by which the substance is used.

 

 

 

[DO NOT READ TO CLIENT] Mark one route only for each substance used. But, if the client identifies more than one route, choose the corresponding route with the highest associated number value (numbers 1 – 6). Responses should capture the past 30 days of use.

 

During the past 30 days, how many days have you used any of the following, and how do you take the substance?

 

This question has two option sets in the form of check boxes (which are optional to select)

• Did not use any substances in the past 30 days.
• REFUSED

 

If “REFUSED” is selected, then system will grey out other check box option “Did not use any substances in the past 30 days” and hide all “Number of Days” for substance use categories.

 

If “Did not use any substances in the past 30 days” is selected, then system will grey out other check box option ‘REFUSED” and hide all “Number of Days” for substances captured under different categories. 

 

DIFFERENT SUBSTANCE USE CATEGORIES WITH SUBSTANCES CAPTURED ON GPRA ASSESSMENT ARE

a. Alcohol

 

 

1. Alcohol
2. Other Alcohol (Specify)

b. Opioids

1. Heroin
2. Morphine
3. Fentanyl (Prescription Diversion Or Illicit Source)
4. Dilaudid
5. Demerol
6. Percocet
7. Codeine
8. Tylenol 2, 3, 4
9. OxyContin/Oxycodone
10. Non-prescription methadone
11. Non-prescription buprenorphine
12. Other Opioids (Specify)

c. Cannabis

1. Cannabis (Marijuana)
2. Synthetic Cannabinoids
3. Other Cannabis (Specify)

 

 

 

 

 

d. Sedative, Hypnotic, or Anxiolytics

1. Sedative
2. Hypnotics
3. Barbiturates
4. Anxiolytics/Benzodiazepines
5. Other Sedative, Hypnotic, or Anxiolytics (Specify)

 

e. Cocaine

1. Cocaine
2. Crack
3. Other Cocaine (Specify)

 

f. Other Stimulants

1. Methamphetamine
2. Stimulant medications
3. Other Stimulants (Specify)

g. Hallucinogens & Psychedelics

 

1. PCP
2. MDMA
3. LSD
4. Mushrooms
5. Mescaline
6. Salvia
7. DMT
8. Other Hallucinogens & Psychedelics (Specify)

h. Inhalants

 

 

1. Inhalants
2. Other Inhalants (Specify)

i. Other Psychoactive Substances

 

1. Non-prescription GHB
2. Ketamine
3. MDP/Bath Salts
4. Kratom
5. Khat
6. Other tranquilizers
7. Other downers
8. Other sedatives
9. Other hypnotics
10. Other Psychoactive Substances (Specify)

j. Tobacco and Nicotine

 

1. Tobacco
2. Nicotine (Including Vape Products)
3. Other Tobacco and Nicotine (Specify)

 

Route (Optional)

• If number greater than ‘0’ is entered for any substance, then system will display ‘Route’ for the corresponding substance.
• It is optional to select ‘Route’ for a substance.
• Different option sets are provided for Route in the form of dropdown values: Oral, Intranasal, Smoking, Non-IV Injection, Intravenous (IV) Injection, Other, Refused

 

 

Other (Specify)

• Each substance use category has ‘Other (Specify)’ field.
• If number greater than ‘0’ is entered, then the system will display a conditional free text entry box for the user to enter details (required) and Route.

 

 

Answer Choice Definitions for Number of Days

1. If number entered as 0 or greater than 0 for ‘Alcohol’, then it is required to have numerical in entry the remaining substances on the screen. The number must be entered as 0 to 30.
2. If ‘Alcohol’ number of days is empty, then you can leave rest of the ‘Number of Days’ blank for other substances.
3. If any ‘Number of Days’ other than ‘Alcohol’ is filled, then it is required to have an ‘Alcohol’ Number of Days as required.

 

 

Section- Previous Diagnosis

2. Have you been diagnosed with an alcohol use disorder, if so which FDA-approved medication did you receive for the treatment of this alcohol use disorder in the past 30 days? [CHECK ALL THAT APPLY] (Optional) 

Intent/Key Points 

 

The intent of this question is to determine whether the client has been diagnosed with an Alcohol use disorder in the past 30 days.

Answer Choice Definitions

CLICK the check box option that best matches the client’s answer:

• Naltrexone
• Extended-release Naltrexone
• Disulfiram
• Acamprosate
• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED ALCOHOL USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• Refused

 

1. If ‘Naltrexone’ is selected, then it is required to enter data in the 'Specify how many DAYS Naltrexone received' numeric text box. Enter data in the range 1 to 30.
2. If ‘Disulfiram’ is selected, then it is required to enter data in the 'Specify how many DAYS Disulfiram received' numeric text box. Enter data in the range 1 to 30.
3. If ‘Acamprosate’ is selected, then it is required to enter data in the ‘Specify how many days Acamprosate received' numeric text box. Enter data in the range 1 to 30.
4. If "Extended-release Naltrexone" is selected, then it is required to enter data in the ‘Specify how many DOSES Extended-release Naltrexone received.’ numeric text box’. Enter data in the range 1 to 2.

 

Notes:

1. You cannot select following option sets if any of the FDA-approved medications are selected.

 

• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED ALCOHOL USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• Refused

2. If ‘DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED ALCOHOL USE DISORDER’ is selected, then, you cannot select following option sets

 

• Naltrexone
• Extended-release Naltrexone
• Disulfiram
• Acamprosate
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• Refused

3. If ‘CLIENT DOES NOT REPORT SUCH A DIAGNOSIS’ selected, then, you cannot select following option sets.

 

• Naltrexone
• Extended-release Naltrexone
• Disulfiram
• Acamprosate
• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED ALCOHOL USE DISORDER
• Refused

4. If ‘REFUSED’ selected, then, you cannot select following option sets.

 

• Naltrexone
• Extended-release Naltrexone
• Disulfiram
• Acamprosate
• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED ALCOHOL USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS

5. User can multi-select all the FDA approved medications for the treatment.

 

3.  Have you been diagnosed with an opioid use disorder, if so which FDA-approved medication did you receive for the treatment of this opioid use disorder in the past 30 days? [CHECK ALL THAT APPLY] (Optional)

Intent/Key Points

The intent of this question is to determine whether the client has been diagnosed with an opioid use disorder in the past 30 days.

Answer Choice Definitions

CLICK the check box option that best matches the client’s answer:

• Methadone
• Buprenorphine
• Naltrexone
• Extended-release Naltrexone
• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED OPIOID USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• REFUSED

1.  If ‘Methadone’ is selected, then it is required to enter data in the 'Specify how many DAYS Methadone received' numeric text box. Enter data in the range 1 to 30.
2. If ‘Buprenorphine’ is selected, then it is required to enter data in the 'Specify how many DAYS Buprenorphine received' numeric text box. Enter data in the range 1 to 30.
3. If ‘Naltrexone’ is selected, then it is required to enter data in the ‘Specify how many days Naltrexone received' numeric text box. Enter data in the range 1 to 30.
4. If "Extended-release Naltrexone" is selected, then it is required to enter data in the ‘Specify how many DOSES Extended-release Naltrexone received.’ numeric text box’. Enter data in the range 1 to 2.

 

Notes:

1. You cannot select following option sets if any of the FDA-approved medications are selected.

 

• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED OPIOID USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• Refused

2. If ‘DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED OPIOID USE DISORDER’ is selected, then, you cannot select following option sets

 

• Methadone
• Buprenorphine
• Naltrexone
• Extended-release Naltrexone
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• REFUSED

3. If ‘CLIENT DOES NOT REPORT SUCH A DIAGNOSIS’ selected, then, you cannot select following option sets.

 

• Methadone
• Buprenorphine
• Naltrexone
• Extended-release Naltrexone
• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED OPIOID USE DISORDER
• REFUSED

4. If ‘REFUSED’ selected, then, you cannot select following option sets.

 

• Methadone
• Buprenorphine
• Naltrexone
• Extended-release Naltrexone
• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED OPIOID USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS

5. User can multi-select all the FDA approved medications for the treatment.

4. Have you been diagnosed with a stimulant use disorder, if so which FDA-approved medication did you receive for the treatment of this stimulant use disorder in the past 30 days? [CHECK ALL THAT APPLY] (Optional)

 

 

Intent/Key Points

The intent of this question is to determine whether the client has been diagnosed with a stimulant use disorder in the past 30 days.

 Answer Choice Definitions

  CLICK the check box option that best matches the client’s answer:

• Contingency Management
• Community Reinforcement
• Cognitive Behavioral Therapy
• Other evidence-based intervention
• DID NOT RECEIVE ANY INTERVENTION FOR A DIAGNOSED STIMULANT USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• REFUSED

1. If ‘Contingency Management’ is selected, then it is required to enter data in the 'Specify how many DAYS Contingency Management received' numeric text box. Enter data in the range 1 to 30.
2. If ‘Community Reinforcement’ is selected, then it is required to enter data in the 'Specify how many DAYS Community Reinforcement received' numeric text box. Enter data in the range 1 to 30.
3. If ‘Cognitive Behavioral Therapy’ is selected, then it is required to enter data in the ‘Specify how many days Cognitive Behavioral Therapy received' numeric text box. Enter data in the range 1 to 30.
4. If ‘Other evidence-based intervention’ is selected, then it is required to enter data in the ‘Specify how many DAYS Other evidence-based intervention received.’ numeric text box’. Enter data in the range 1 to 30.

 

Notes:

1. You cannot select following option sets if any of the INTERVENTIONS are selected.

 

• DID NOT RECEIVE ANY INTERVENTION FOR A DIAGNOSED STIMULANT USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• REFUSED

2. If ‘DID NOT RECEIVE ANY INTERVENTION FOR A DIAGNOSED STIMULANT USE DISORDER’ is selected, then, you cannot select following option sets.

 

• Contingency Management
• Community Reinforcement
• Cognitive Behavioral Therapy
• Other evidence-based intervention
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• REFUSED

3. If ‘CLIENT DOES NOT REPORT SUCH A DIAGNOSIS’ selected, then, you cannot select following option sets.

 

• Contingency Management
• Community Reinforcement
• Cognitive Behavioral Therapy
• Other evidence-based intervention
• DID NOT RECEIVE ANY INTERVENTION FOR A DIAGNOSED STIMULANT USE DISORDER’
• REFUSED

4. If ‘REFUSED’ selected, then, you cannot select following option sets.

 

• Contingency Management
• Community Reinforcement
• Cognitive Behavioral Therapy
• Other evidence-based intervention
• DID NOT RECEIVE ANY INTERVENTION FOR A DIAGNOSED STIMULANT USE DISORDER’
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS

5. User can multi-select all the FDA approved INTERVENTIONS for the treatment.

 

5. Have you been diagnosed with a tobacco use disorder, if so which FDA-approved medication did you receive for the treatment of this tobacco use disorder in the past 30 days? [CHECK ALL THAT APPLY] (Optional)

Intent/Key Points

The intent of this question is to determine whether the client has been diagnosed with a tobacco use disorder in the past 30 days.

Answer Choice Definitions

CLICK the check box option that best matches the client’s answer:

• Nicotine Replacement
• Bupropion
• Varenicline
• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED TOBACCO USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• REFUSED

1. If ‘Nicotine Replacement’ is selected, then it is required to enter data in the 'Specify how many DAYS Nicotine Replacement received' numeric text box. Enter data in the range 1 to 30.
2. If ‘Bupropion’ is selected, then it is required to enter data in the 'Specify how many DAYS Bupropion received' numeric text box. Enter data in the range 1 to 30.
3. If ‘Varenicline’ is selected, then it is required to enter data in the ‘Specify how many DAYS Varenicline received' numeric text box. Enter data in the range 1 to 30.

 

Notes:

1. You cannot select following option sets if any of the FDA-approved medications are selected.

 

• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED TOBACCO USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• Refused

2. If ‘DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED TOBACCO USE DISORDER’ is selected, then, you cannot select following option sets.

 

• Nicotine Replacement
• Bupropion
• Varenicline
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS
• REFUSED

3. If ‘CLIENT DOES NOT REPORT SUCH A DIAGNOSIS’ selected, then, you cannot select following option sets.

 

• Nicotine Replacement
• Bupropion
• Varenicline
• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED TOBACCO USE DISORDER
• REFUSED

4. If ‘REFUSED’ selected, then, you cannot select following option sets.

 

• Nicotine Replacement
• Bupropion
• Varenicline
• DID NOT RECEIVE AN FDA-APPROVED MEDICATION FOR A DIAGNOSED TOBACCO USE DISORDER
• CLIENT DOES NOT REPORT SUCH A DIAGNOSIS

5. User can multi-select all the FDA approved medications for the treatment.

 

Section- Substance Use Continued

6. In the past 30 days, did you experience an overdose or take too much of a substance that resulted in needing supervision or medical attention? (Optional)

Intent/Key Points

 

 

 

The intent of this question is to determine whether the client did experience an overdose or take too much of a substance that resulted in needing supervision or medical attention.

Answer Choice Definitions

CLICK the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

 

If ‘Yes’ is selected, then system displays an additional question as a response.

 

7. [IF YES] In the past 30 days, after taking too much of a substance or overdosing, what intervention did you receive? You may indicate more than one. (Optional)

Intent/Key Points

The intent of this question is to determine whether the client received any intervention after taking too much of a substance in the past 30 days.

Answer Choice Definitions

CLICK the check boxes options that best matches the client’s answer:

• Naloxone (Narcan)
• Care in an Emergency Department
• Care from a Primary Care Provider
• Admission to a hospital
• Supervision by someone else
• Other (Specify)
• Refused

1. Multi- selection of intervention option sets can be done including Other (Specify)
2. If ‘Other (Specify)’ is selected, then conditional text box is available for the user to enter text. And, it is required to have an entry in the text box.
3. In the option sets, if ‘Refused’ is selected, then you will not be able to select any of the intervention set option.

8. Not including this current episode, how many times in your life have you been treated at an inpatient, or outpatient facility for a substance use disorder. (Optional)

 

 

Intent/Key Points

The intent of this question is to determine how many times in the life of client been treated at an inpatient, or outpatient facility for a substance use disorder.

Answer Choice Definitions

CLICK the radio button option that best matches the client’s answer:

• One time
• Two Times
• Three Times
• Four Times
• Five Times
• Six Times or more
• Never
• Refused

In these answer choices, If One Time, Two Times, Three Times, Four Times, Five Times, Six or more times is selected, then system displays an additional question as following

9. Approximately when was the last time you received inpatient or outpatient treatment for a substance use disorder? (Optional)

Intent/Key Points

The intent of this question is to determine when was the last time client received inpatient or outpatient treatment for a substance use disorder.

 

Answer Choice Definitions

CLICK the radio button option that best matches the client’s answer:

• Less than 6 months ago
• Between 6 months and one year ago
• One to two years ago
• Two to three years ago
• Three to four years ago
• Five or more years ago
• REFUSED

Section- Mental Health

10. Have you ever been diagnosed with a mental health illness by a health care professional? (Optional)

Intent/Key Points

The intent of this question is to determine have the client ever been diagnosed with a mental health illness by a health care professional.

Answer Choice Definitions

CLICK the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

If ‘Yes’ is selected as an answer choice, then system will display check boxes under different mental health illness categories along with None of the Above and Refused option sets mentioned in 10a. [IF YES] PLEASE ASK THE CLIENT TO SELF-REPORT THEIR MENTAL HEALTH ILLNESSES AS LISTED IN THE TABLE BELOW. THE CLIENT SHOULD BE ENCOURAGED TO REPORT THEIR OWN MENTAL HEALTH ILLNESSES BUT IF PREFERRED, THE LIST CAN BE READ TO THE CLIENT. PLEASE INDICATE ALL THAT APPLY. As following

Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders

Answer Choice

• Brief psychotic disorder
• Delusional disorder
• Schizoaffective disorders
• Schizophrenia
• Schizotypal disorder
• Shared psychotic disorder
• Unspecified psychosis

Mood [affective] disorders

Answer Choice

• Bipolar disorder
• Major depressive disorder, recurrent
• Major depressive disorder, single episode
• Manic episode
• Persistent mood [affective] disorders
• Unspecified mood [affective] disorder

Phobic Anxiety and Other Anxiety Disorders

Answer Choice

• Agoraphobia without panic disorder
• Agoraphobia with panic disorder
• Agoraphobia, unspecified
• Generalized anxiety disorder
• Panic disorder
• Phobic anxiety disorders
• Social phobias (Social anxiety disorder)
• Specific (isolated) phobias

Obsessive-compulsive disorders

Answer Choice

• Excoriation (skin-picking) disorder
• Hoarding disorder
• Obsessive-compulsive disorder
• Obsessive-compulsive disorder with mixed obsessional thoughts and acts

Reaction to severe stress and adjustment disorders

Answer Choice

• Acute stress disorder; reaction to severe stress, and adjustment disorders
• Adjustment disorders
• Body dysmorphic disorder
• Dissociative and conversion disorders
• Dissociative identity disorder
• Post traumatic stress disorder
• Somatoform disorders

Behavioral syndromes associated with physiological disturbances and physical factors

Answer Choice

• Eating disorders
• Sleep disorders not due to a substance or known physiological condition

Disorders of adult personality and behavior

Answer Choice

• Antisocial personality disorder
•  Avoidant personality disorder
• Borderline personality disorder
• Dependent personality disorder
• Histrionic personality disorder
• Intellectual disabilities
• Obsessive-compulsive personality disorder
• Other specific personality disorders
• Paranoid personality disorder
• Personality disorder, unspecified
• Pervasive and specific developmental disorders
• Schizoid personality disorder

Check here to indicate NONE OF THE ABOVE or if the client REFUSED to provide their mental health illnesses.

This question has two check box options: NONE OF THE ABOVE AND REFUSED

ANSWER CHOICE DEFINITION

• CLICKING on ‘None of the Above’ option will hide all the mental health illness check box option sets and system will grey out ‘Refused’ option set check box.
• CLICKING on ‘REFUSED’ option will hide all the mental health illness check box option sets and grey out ‘None of Above’.
• Multi-selection of the mental health illness option sets can be done in the section.
• CLICKING on mental health illness option sets can hide None of the Above and Refused options.

 

Section- Co-Occuring Mental Health and Substance Use Disorders

This section is only applicable to the Initial GPRA Assessment

11. Was the client screened by your program, using an evidence-based tool or set of questions, for co-occurring mental health and/or substance use disorders? (Optional)

Intent/Key Points

The intent of this question is to determine whether your program conducted a co-occurring disorders screening. The presence of a co-occurring mental disorder may affect the likelihood of long-term recovery from a substance use disorder.

Answer Choice Definitions

• CLICK the radio button option that best matches the client’s answer:
  • “Yes”— The client was screened by your program for co-occurring mental health and substance use disorders.
  • “No”— The client was not screened by your program for co-occurring mental health and substance use disorders.

Notes

• If "Yes" is selected, then the system will expand and display question 11a. along with 2 radio button options.
• If "No" is selected, then continue to the Planned Services tab.
• For Follow-up and Discharge assessments, the system will hide question on Substance Use Tab.

11a. [IF YES] Did the client screen positive for co-occurring mental health and substance use    disorders? (Optional)

Intent/Key Points

The intent of this question is to determine whether the client screened positive for co-occurring mental health and substance use disorders. The presence of a co-occurring mental disorder may affect the likelihood of long-term recovery from a substance use disorder.

Answer Choice Definitions

• CLICK the radio button option that best matches the client’s answer:
  • “Yes”— The client was screened positive by your program for co-occurring mental health and substance use disorders.
  • “No” — The client did not screen positive by your program for co-occurring mental health and substance use disorders.

Notes

• If "Yes" is selected, then the system will expand and display question 11b. along with 2 radio button options.
• If "No" is selected, then continue to the Planned Services tab.

11b. [IF YES TO QUESTION 11a] Was the client referred the further assessment for a co-occurring mental health and substance use disorder? (Optional)

Intent/Key Points

The intent of this question is to determine whether the client was referred for further assessment for a co-occurring mental health and substance use disorder.

Answer Choice Definitions

• CLICK the radio button option that best matches the client’s answer:
  • “Yes”— The client was referred for further assessment for a co-occurring mental health and substance use disorder.
  • “No” — The client was not referred for further assessment for a co-occurring mental health and substance use disorder.

Notes

• If "Yes" is selected, then the system will expand and display question 11b. along with 2 radio button options.
• If "No" is selected, then continue to the Planned Services tab.

 

 

 

 

 

 

 

 

 

 

 

Planned Services Information

OVERVIEW

This section pertains to the client’s planned services information. Identify the services you plan to provide to the client during the client’s course of treatment/recovery. Record only planned services that are provided with state funding under the contract this client is served by. For example, if you have a contract with HHSC to provide opioid treatment services, you will only report services you plan to offer under the scope of that contract. Likewise, if you have a contract with HHSC to provide recovery support services (RSS), you will also only report services you plan to offer under the scope of your RSS contract. If you plan to offer services to a client from different funding, such as a separate grant you receive or through self-pay options, these services should not be included on this assessment. To minimize the time needed to complete this page, all answer choices will default to “No”. You must review each service and select “Yes” for those you plan to provide.

This section is filled out by you while conducting the assessment; the questions are not asked of the client.

MODALITY [SELECT AT LEAST ONE MODALITY]

1. Case Management
2. Intensive Outpatient Treatment
3. Inpatient/Hospital (Other Than Withdrawal Management)
4. Outpatient Therapy
5. Outreach
6. Medication Methadone
   1. 1. Buprenorphine
      2. Naltrexone - Short Actine
      3. Naltrexone – Long Actine
      4. Disulfiram
      5. Acamprosate
      6. Nicotine Replacement
      7. Bupropion
      1. Varenicline
7. Residential/Rehabilitation
8. Withdrawal Management (select only one
   • Hospital Inpatient
   • Free-Standing Residential
   • Ambulatory Detoxification
9. After Care
10. Recovery Support
11. Other (Specify)—Specify any other service modalities to be received by the client.

Notes:

• You can ONLY select "Yes" or "No" radio button for each field, missing values are not allowed.
• Default value "No" is set for all radio buttons.  
• You must select "Yes" for at least one Modality.
• You can only select “Yes” for one option under Modality # 8. Withdrawal Management
• If ‘Other (Specify)’ is selected, then the system will display a numeric text box for the user to enter text with field name ‘Other (Specify Modality)’ and it is a required numeric text box.

[SELECT AT LEAST ONE SERVICE] from the following service types:

TREATMENT SERVICES

1. Screening
2. Brief Intervention
3. Brief Treatment
4. Referral to Treatment
5. Assessment
6. Treatment Planning
7. Individual Counseling
8. Group Counseling
9. Contingency Management
10. Community Reinforcement
11. Cognitive Behavioral Therapy
12. Family/Marriage Counseling
13. Co-Occurring Treatment Services
14. Pharmacological Intervention
15. HIV/AIDS Counseling
16. Cultural Interventions/Activities
17. Other Clinical Services (Specify)—Other client services the client received that are not listed above.

CASE MANAGEMENT SERVICES

1. Family Services (E.g., Marriage Education, Parenting, Child Development Services)
2. Child Care
3. Employment Services
   • Pre-Employment Services
   • Employment Coaching
4. Individual Services Coordination
5. Transportation
6. HIV/AIDS Service
   1. 1. If HIV Neg, Pre-Exposure Prophylaxis
      2. If HIV Neg, Post-Exposure Prophylaxis
      3. If HIV Positive, HIV Treatment
7. Transitional Drug-Free Housing Services
8. Housing Support
9. Health Insurance Enrollment
10. Other Case Management Services (Specify)—Other case management services the client received that are not listed above.

MEDICAL SERVICES

1. Medical Care
2. Alcohol/Drug Testing
3. OB/GYN Services
4. HIV/AIDS Medical Support & Testing
5. Dental Care
6. Viral Hepatitis Medical Support & Testing
7. Other STI Support & Testing
8. Other Medical Services —Other medical services the client received that are not listed above.

AFTER CARE SERVICES

1. Continuing Care
2. Relapse Prevention
3. Recovery Coaching
4. Self-Help and Mutual Support Groups
5. Spiritual Support
6. Other After Care Services—Other after care services the client received that are not listed above.

EDUCATION SERVICES

1. Substance Abuse Education
2. HIV/AIDS Education
3. Naloxone Training
4. Fentanyl Test Strip Training
5. Viral Hepatitis Education
6. Other STI Education Services
7. Other Education Services (Specify)—Other education services the client received that are not listed above.

Recovery Support Services

1. Peer Coaching or Mentoring
2. Vocational Services
3. Recovery Housing
4. Recovery Planning
5. Case Management Services to Specifically Support Recovery
6. Alcohol-and Drug-Free Social Activities
7. Information and Referral
8. Other Recovery Support Services
9. Other Peer-to-Peer Recovery Support Services

Notes:

• You can ONLY select "Yes" or "No" radio button for each field, missing values are not allowed.
• Default value "No" is set for all radio buttons.  
• You must select "Yes" for at least one service.

Living Conditions

1. In the past 30 days, where have you been living most of the time? [DO NOT READ OPTIONS TO CLIENT.] (Optional)

Intent/Key Points

The intent of this question is to determine where the client have been living most of the time.

It is an optional field to save the document.

Answer Choice Definitions

Select the drop-down option that best matches the client’s answer:

• Shelter (Safe Havens, Transitional Living Center [TLC], Low-Demand Facilities, Reception Centers, Other Temporary Day or Evening Facility)
• Street/Outdoors (Sidewalk, Doorway, Park, Public Or Abandoned Building)
• Institution (Hospital, Nursing Home, Jail/Prison)
• Housed
• Refused

If ‘Housed’ is selected as an option set, then system display an additional question.

2. [IF HOUSED, CHECK APPROPRIATE SUBCATEGORY:] (Optional)

Intent/Key Points

The intent of this question is to determine the housing details for the client.

Answer Choice Definitions

Select the drop-down option that best matches the client’s answer:

• Own/Rental apartment, room, trailer, or house
• Someone else's apartment, room, trailer, or house
• Dormitory/College Residence
• Halfway house or Transitional Housing
• Residential Treatment
• Recovery Residence/Sober Living
• Other Housed (Specify)

Notes:

• If ‘Other (Specify)’ is selected, then the system will display a numeric text box for the user to enter text with field name ‘Please Specify’ and it is a required numeric text box.

3. Do you currently live with any person who, over the past 30 days, has regularly used alcohol or other substances? (Optional)

Intent/Key Points

The intent of this question is to determine whether the client live with any person who, over the past 30 days, has regularly used alcohol or other substances?

It is an optional field to save the document.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

•  Yes
•  No
• No, lives alone
• Refused

Legal

This tab gathers information about arrests and incarceration or detainment. Even if the client is court mandated to receive treatment, these questions must be asked, and the client’s answers recorded.

1. In the past 30 days, how many times have you been arrested? [IF THE CLIENT INDICATES NO ARRESTS IN THE PAST 30 DAYS, BUT IS INCARCERATED AT THE TIME OF THE INTERVIEW, MARK CURRENTLY INCARCERATED] (Optional)

Intent/Key Points

The intent of this question is to determine how many times the client been arrested or if the client is incarcerated at the time of interview in last past 30 days.

Answer Choice Definitions

• If the client Refused to provide the number of times arrested or incarceration status., then you cannot enter value in How many arrests numeric text box and you cannot check the check box ‘Currently Incarcerated’.
• However, if the client indicates arrests in the past 30 days, you can also check ‘Currently Incarcerated’ check box at the same time, but it is not required. At this time, the system would hide ‘Refused’ check box.
• In the ‘How many arrests’ numeric text box, you can enter values between 0-99.

2. Are you currently awaiting charges, trial, or sentencing? (Optional)

Intent/Key Points

The intent of this question is to determine currently awaiting charges, trial, or sentencing of the client.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

3. Do you currently participate in a drug court program or are you in a deferred prosecution agreement?

Intent/Key Points

The intent of this question is to determine currently awaiting charges, trial, or sentencing of the client.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Probation
• Parole
• Intensive Pretrial Supervision
• No
• Refused

4. Are you currently on parole or probation or intensive pretrial supervision? (Optional)

Intent/Key Points

The intent of this question whether the client currently participate in a drug court program or are you in a deferred prosecution agreement.

It is an optional field to save the document.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Drug court program
• Deferred prosecution agreement
• No, neither of these
• Refused

Mental and Physical Health

OVERVIEW

This Tab addresses issues of mental and physical health of the client in the past 30 days.

1. How would you rate your quality of life over the past 30 days? (Optional)

Intent/Key Points

The intent of this question is to determine the rating of the quality of life in the past 30 days.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Very Poor
• Poor
• Neither poor nor good
• Good
• Very Good
• Refused

2. In the past 30 days, how many days have you [ENTER '0' IN DAYS IF THE CLIENT REPORTS THAT THEY HAVE NOT EXPERIENCED THE CONDITION. SELECT REFUSED FOR NO RESPONSE] (Optional)

Intent/Key Points

The intent of this question is to determine the experienced condition of the client.

Answer Choice Definitions

Different health conditions are given in the question as following:

a. Experienced serious depression

b. Experienced serious anxiety or tension 

c. Experienced hallucinations

d. Experienced trouble understanding, concentrating, or remembering.

e. Experienced trouble controlling violet behavior.

f. Attempted suicide

g. Been prescribed medication for psychological/emotional problem.

Each Health condition is provided with ‘Refused’ option. You can select ‘Refused’ check box, in case, Client Refused to provide the information for any of the experienced health condition.

If the client is reporting an experienced health condition, then you can enter values in the range 0-30 in the given numeric text box for the corresponding health condition.

3. How much have you been bothered by these psychological or emotional problems in the past 30 days? (Optional)

Intent/Key Points

The intent of this question is to determine whether the client is bothered by the psychological or emotional problems in the past 30 day.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Not at all
• Slightly
• Moderately
• Considerably
• Extremely
• No reported mental health complaints in the past 30 days
• Refused

4. In the past 30 days, where have you gone to receive medical care? You may select more than one response. (Optional)

Intent/Key Points

The intent of this question is to determine where the client received medical care in the past 30 days.

Answer Choice Definitions

Select the check box option that best matches the client’s answer:

• Primary Care Provider
• Urgent Care
• The Emergency Department
• A specialist doctor
• No care was sought
• Other (Specify)
• REFUSED

NOTE:

1. If REFUSED is selected as a option set, then you would not be able to select any medical care option set including Other (Specify).
2. If REFUSED is not selected, you can multi-select medical care options including Other (Specify) option.
3. If Other (Specify) is selected, then you can enter other medical care in Other (Specify Medical Care) text box and it is required text box.

5. Do you currently have medical/health insurance? (Optional)

Intent/Key Points

The intent of this question is to determine the medical/health insurance.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

If the client is receiving the medical/health insurance, then the system will display another question for the user to answer:

5a. What type of insurance do you have [CHECK ALL THAT APPLY]? (Optional)

Intent/Key Points

The intent of this question is to determine the type of insurance client have.

It is an optional field to save the document.

Answer Choice Definitions

Select the check box option that best matches the client’s answer:

• Medicare
• Medicaid
• Private Insurance or Employer Provided
• TRICARE or other military health care
• An assistance program [for example, a medication assistance program]
• Any other type of health insurance or health coverage plan (Specify)
• REFUSED

Notes:

1. If REFUSED is selected as an option set, then you would not be able to select any medical/health insurance option set including Any other type of health insurance or health coverage plan (Specify).
2. If REFUSED is not selected, you can multi-select medical/health insurance option including Any other type of health insurance or health coverage plan (Specify)
3. If ‘Any other type of health insurance or health coverage plan (Specify)’ is selected, then you can enter other medical/health insurance in Other (Specify Medical Insurance) text box and it is required text box.

 

Social Connectedness

1. In the past 30 days, did you attend any voluntary mutual support groups for recovery? In other words, did you participate in a non-professional, peer-operated organization that assists individuals who have addiction-related problems such as: Alcoholics Anonymous, Narcotics Anonymous, Secular Organization for Sobriety, Women for Sobriety, religious/faith-affiliated recovery mutual support groups, etc.? Attendance could have been in person or virtual. (Optional)

Intent/Key Points

The intent of this question is to determine whether the client has attended any voluntary mutual support groups for recovery in the past 30 days.

It is an optional field to save the document.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

IF ‘Yes’ is selected in above mentioned question, then system displays two questions as following.

[IF YES] Specify How Many Times:

Check here if the client REFUSED to provide the number of times attended any voluntary mutual support groups for recovery. 

Notes:

1. [IF YES] Specify How Many Times has a control type of numeric text box which is optional to save the GPRA Assessment in the system. This numeric text box accepts numbers between 1-99.
2. The system provides ‘Refused’ check box with question “Check here if the client REFUSED to provide the number of times attended any voluntary mutual support groups for recovery” and it is an optional check box.

 

If ‘Refused’ check box is checked, then the numeric text box would be hidden and vice versa. Ideally, you cannot enter a text in the numeric text box with the selection of Refused check box.

2. In the past 30 days, did you have interaction with family and/or friends that are supportive of your recovery? (Optional)

Intent/Key Points

The intent of this question is to determine an interaction of the client with family and/or friends that are supportive of your recovery.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

3. How satisfied are you with your personal relationships? (Optional)

Intent/Key Points

The intent of this question is to find out how satisfied the client is with his personal relationships.

It is an optional field to save the document.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Very Dissatisfied
• Dissatisfied
• Neither Satisfied nor Dissatisfied
• Satisfied
• Very Satisfied
• Refused

4. In the past 30 days did you realize that you need to change those social connections or places that negatively impact your recovery? (Optional)

Intent/Key Points

The intent of this question is to determine whether the client realized that he/she need to change those social connections or places that negatively impact your recovery in the past 30 days.

It is an optional field to save the document.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Yes
• No
• Refused

Follow Up Status

OVERVIEW

This section pertains to the client’s status at the 6-month follow-up assessment. This section is filled out by you while conducting the assessment; the questions are not asked of the client.

GPRA follow-up assessments should be completed the number of months specified (6) from the GPRA intake/baseline assessment date. HHSC provides a window period of time for these GPRA follow-up assessments to be conducted. The window period allowed for these GPRA follow-up assessments is one month before the (6 month) anniversary date and up to two months after the (6 month) anniversary date. For example:

• If a client receives the GPRA intake/baseline assessment on January 1st, the 6-month follow-up anniversary date would be July 1st. The window period for conducting the 6-month follow-up assessment would open one month before the anniversary date on June 1st, and close two months after the anniversary date on September 1st.

 1. Was the client able to be contacted for follow-up? (Required)

Intent/Key Points

The intent of this question is to determine whether the client was able to be contacted for follow up.

It is a required field to save the assessment in Ready for Review and Closed Complete status.

Answer Choice Definitions

Select the radio button option that best matches the client’s answer:

• Yes
• No

Note:

1. If ‘Did you conduct the interview? ‘Is answered as ‘Yes’ on Record Management of 6-month Follow Up GPRA Assessment, then the ‘Was the client able to be contacted for follow-up? Can only be answered as ‘Yes’ on screen.
2. If ‘Did you conduct the interview? ‘Is answered as ‘No’ on Record Management of 6-month Follow Up GPRA Assessment, then the ‘Was the client able to be contacted for follow-up? Can only be answered as ‘Yes’ or ‘No’ on screen.

2. What is the follow-up status of the client? (Required)

Intent/Key Points

The intent is to document the client’s status at the 6-month follow-up time point and the project’s effort to complete the assessment. Select the response that best fits.

Answer Choice Definitions

CLICK ON only one option.

a. If you select ‘Yes’ on ‘Did you conduct the interview’ question on ‘Record Management’ of 6-month follow up GPRA Assessment, and, ‘Yes’ to ‘Was the client able to be contacted for follow-up?’  then you can only go with following options.

• Completed interview within specified window
• Completed interview outside specified window

b.  If you select ‘No’ on ‘Did you conduct the interview’ question on ‘Record Management’ of 6-month follow up GPRA Assessment, and, ‘Yes’ to ‘Was the client able to be contacted for follow-up?’ then you can only go with following options.

• Located, but Refused, unspecified
• Located, but unable to gain institutional access
• Located, but otherwise unable to gain access
• Located, but withdrawn from project
• Unable to locate, moved
• Unable to locate, other (specify)

Note: If the client is unable to locate, then enter text in ‘Other (Specify Follow-Up Status) text box and it is a required text box.

c. If you select ‘No’ on ‘Did you conduct the interview’ question on ‘Record Management’ of 6-month follow up GPRA Assessment, and, ‘No’ to ‘Was the client able to be contacted for follow-up?’ then you can only go with following options.

 

• Deceased at time of due date
• Located, but Refused, unspecified
• Located, but unable to gain institutional access
• Located, but otherwise unable to gain access
• Located, but withdrawn from project
• Unable to locate, moved
• Unable to locate, other (specify)

Note: If the client is unable to locate, then enter text in ‘Other (Specify Follow-Up Status) text box and it is a required text box.

3. Is the client still receiving services from your program? (Required)

Intent/Key Points

The intent is to record whether HHSC-funded services are ongoing for the client at your agency at the time of the follow-up assessment.

Answer Choice Definitions

• SELECT the radio button that best corresponds to the client’s situation: “Yes” or “No”

 

 

 

 

 

 

 

 

 

 

Discharge Status Information

OVERVIEW

The information in this section pertains to the client’s discharge status. This information is only completed at discharge. This section is filled out by you while conducting the assessment; the questions are not asked of the client.

A discharge assessment is completed when an admitted client will no longer be receiving any services from the provider. The discharge assessment documents the client’s problems and needs at admission, progress or lack of progress during treatment, and the circumstances of the discharge, including the client’s condition and living situation at discharge.

Although only a subgroup of the initial assessment questions must be answered for the discharge assessment, they are primarily questions that address the client’s current condition in the 30 days prior to discharge. It is the responsibility of the clinician to review all the assessment questions and enter any other important information about the client.

1. On what date was the client discharged? (Required)

Intent/Key Points

The intent of the question is to determine when the client was discharged from the program, whether the discharge was voluntary or involuntary. Enter the date the client was discharged, not the date of the discharge assessment.

Answer Choice Definitions

• TYPE IN date as mm/dd/yyyy.

2. What is the client’s discharge status? (Required)

Intent/Key Points

The intent of this question is to determine the client’s discharge status.

Note that this is a two-part question. If the client completed or graduated from the program, check “completion/graduate.” If the client was terminated from the program, check “termination” and indicate the reason for the client’s termination from the program using the response options from the list provided. If the reason for termination is not on the list, choose “other” and give the reason.

Answer Choice Definitions

• SELECT the radio button that best corresponds to the reason the client is leaving the program
  • “Completion/Graduate”
  • “Termination”

If you choose “Termination” then CLICK ON termination reason from the drop-down list in the question 2a. If the client was terminated, what was the reason for termination?

Choose only one.

• Left on own against staff advice with satisfactory progress
• Left on own against staff advice without satisfactory progress
• Involuntarily discharged due to nonparticipation
• Involuntarily discharged due to violation of rules
• Referred to another program or other services with satisfactory progress
• Referred to another program or other services with unsatisfactory progress
• Incarcerated due to offense committed while in treatment with satisfactory progress
• Incarcerated due to offense committed while in treatment with unsatisfactory progress
• Incarcerated due to old warrant or charge from before entering treatment with satisfactory progress
• Incarcerated due to old warrant or charge from before entering treatment with unsatisfactory progress
• Transferred to another facility for health reasons
• Death
• Other (Specify)

Notes:

If Other (Specify) is selected in question 2a. If the client was terminated, what was the reason for termination?’ then enter the reason in the text box given under field ‘Other (Specify Termination Reason)’.  

3. Did the program order an HIV test for this client? (Optional)

Intent/Key Points

The intent is to record whether or not the client was ordered for an HIV test.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• • Yes—The program tested this client for HIV.
  • No—The program did not test this client for HIV.

 4. [IF NO] Did the program refer this client for HIV testing with another provider? (Required)

Intent/Key Points

The intent is to record whether or not the program referred this client for HIV testing.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes—The program referred this client for HIV testing.
• No—The program did not refer this client for HIV testing.

5. Did the program provide Naloxone and/or Fentanyl Test Strips to this client at any time during their involvement in grant funded services? (Optional)

Intent/Key Points

The intent is to record whether the program provided Naloxone and/or Fentanyl Test Strips to this client at any time during their involvement in grant funded services.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Naloxone
• Fentanyl Test Strips
• Both Naloxone and Fentanyl Test Strips
• Neither

6. Is the client fully vaccinated against the virus that causes COVID-19? (Optional)

Intent/Key Points

The intent is to record whether the client is fully vaccinated against the virus that causes COVID 19.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No, partially vaccinated with plans to receive the subsequent vaccination on time
• No, partially vaccinated with no plan to receive the subsequent vaccination
• No, client refused vaccination
• Refused to answer

Services Received Information

1. Identify the number of DAYS of services to the client during the client’s course of treatment/recovery. [ENTER ZERO IF NO SERVICES PROVIDED. YOU SHOULD HAVE AT LEAST ONE DAY FOR MODALITY.]

MODALITY (Required)

Enter the number of DAYS of services provided during the client’s course of treatment/recovery.

1. Case Management
2. Intensive Outpatient Treatment
3. Inpatient/Hospital (Other Than Withdrawal Management)
4. Outpatient Therapy
5. Outreach
6. Medication
   1. 1. Methadone
      2. Buprenorphine
      3. Naltrexone – Short Acting
      4. Naltrexone -Long Acting (Report 28 days for each one injection)
      5. Disulfiram
      6. Acamprosate
      7. Nicotine Replacement
      8. Bupropion
      9. Varenicline
7. Residential/Rehabilitation
8. Withdrawal Management (Select Only 1):
   1. 1. Hospital Inpatient
      2. Free Standing Residential
      3. Ambulatory Detoxification
9. After Care
10. Recovery Support
11. Other (Specify) —specify any other service modalities to be received by the client.

Notes:

• CMBHS will enter a default value of 0 for all services.
• User should enter at least one day for modality otherwise an error message will be displayed." You must enter at least one day of services within the modality section."
• In the ‘Withdrawal Management’ options, You can select only one option out of three.
• Other (Specify)  is greater than 0, then TYPE IN any other service modalities that the client is expected to receive in ‘Other (Specify Modality).

Identify the number of SESSIONS provided to the client during the client’s course of treatment/recovery. [ENTER ZERO IF NO SERVICES PROVIDED. YOU SHOULD HAVE AT LEAST ONE SESSION IN ONE SERVICE CATEGORY.]

TREATMENT SERVICES

1. Screening
2. Brief Intervention
3. Brief Treatment
4. Referral to Treatment
5. Assessment
6. Treatment Planning
7. Individual Counseling
8. Group Counseling
9. Contingency Management
10. Community Reinforcement
11. Cognitive Behavioral Therapy
12. Family/Marriage Counseling
13. Co-Occurring Interventions
14. Pharmacological Interventions
15. HIV/AIDS Counseling
16. Cultural Interventions/Activities
17. Other Clinical Services (Specify)—other client services the client received that are not listed above.

Notes:

• CMBHS will enter a default value of 0 for all services.
• Other Clinical Services (Specify) is greater than 0, then TYPE IN any other Treatments that the client is expected to receive in the text box ‘Other (Specify Clinical Services)

CASE MANAGEMENT SERVICES (Required)

1. Family Services (Including Marriage Education, Parenting, and Child Development Services)
2. Child Care
3. Employment Services
   1. 1. Pre-Employment Services
      2. Employment Coaching

 

4. Individual Services Coordination
5. Transportation
6. HIV/AIDS Service
7. Transitional Drug-Free Housing Services
8. Housing Support
9. Health Insurance Enrollment
10. Other Case Management Services (Specify)—other case management services the client received that are not listed above.

Notes:

• CMBHS will enter a default value of 0 for all services.
• Other Case Management Services (Specify) is greater than 0, then TYEPE IN any other Treatments that the client is expected to receive in field ‘Other (Specify Case Management Services).

MEDICAL SERVICES

1. Medical Care
2. Alcohol/Drug Testing
3. OB/GYN Services
4. HIV/AIDS Medical Support & Testing
5. Other STI Support and Testing
6. Dental Care
7. Other Medical Services (Specify)—other medical services the client received that are not listed above.

Notes:

• CMBHS will enter a default value of 0 for all services.
• Other Medical Services (Specify) is greater than 0, then, TYPE IN any other Treatments that the client is expected to receive in ‘Other (Specify Medical Services).

AFTER CARE SERVICES

1. Continuing Care
2. Relapse Prevention
3. Recovery Coaching
4. Self-Help and Support Groups
5. Spiritual Support
6. Other After Care Services (Specify)—other after care services the client received that are not listed above.

Notes:

• CMBHS will enter a default value of 0 for all services.
• Other After Care Services is greater than 0, then, TYPE IN any other After Care Services that the client is expected to receive in free text box ‘Other (Specify After Care Services)’.

EDUCATION SERVICES

1. Substance Misuse Education
2. HIV/AIDS Education
3. Hepatitis Education
4. Other STI Education Services
5. Naloxone Training
6. Fentanyl Test Strip Training
7. Other Education Services (Specify)—other education services the client received that are not listed above.

Notes:

• CMBHS will enter a default value of 0 for all services.
• Other (Specify Education Services) is greater than 0, then, TYPE IN any other Education Services that the client is expected to receive.

RECOVERY SUPPORT SERVICES

1. Peer Coaching or Mentoring
2. Vocational Services
3. Recovery Housing
4. Recovery Planning
5. Case Management Services to Specifically Support Recovery
6. Alcohol-and Drug-Free Social Activities
7. Information and Referral
8. Other Recovery Support Services (Specify)
9. Other Peer-to-Peer Recovery Support Services (Specify)—other peer-to-peer recovery services the client received that are not listed above.

Notes:

• CMBHS will enter a default value of 0 for all services.
• Other Recovery Support Services (Specify) value is greater than 0, then, TYPE IN any Other Recovery Support Services that the client is expected to receive in the free text box of field ‘Other (Specify Recovery Support Services).
• Other Peer-to-Peer  (Specify) value is greater than 0, then, TYPE IN any Other Recovery Support Services that the client is expected to receive in the free text box of field ‘Other (Specify Peer Recovery Support Services).

2. Has this client attended 60% or more of their planned services? (Optional)

Intent/Key Points

The intent is to record whether the client attended 60% or more of the planned services.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No

 

3. Did this client receive any services via telehealth or a virtual platform? (Optional)

Intent/Key Points

The intent is to record whether the client receive any services via telehealth or a virtual platform.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No

 

4. Has this client previously been diagnosed with an opioid use disorder? (Optional)

Intent/Key Points

The intent is to record whether the client previously been diagnosed with an opioid use disorder.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No

 

If ‘Yes’ is selected in above question then system displays following question:

 

4a. [IF YES] In the past 30 days, which FDA-approved medication did the client receive for the treatment of this opioid use disorder? [CHECK ALL THAT APPLY.] (Optional)

Intent/Key Points

The intent is to record whether the client received FDA-approved medication for the treatment of the opioid use disorder.

Answer Choice Definitions

SELECT the check box for the answer that best applies:

• Methadone
• Buprenorphine
• Naltrexone
• Extended-release Naltrexone
• Client did not receive an FDA-approved medication for a diagnosed opioid use disorder

Notes:

 

• If any of the FDA-approved medication is selected, then, you cannot select check box option ‘Client did not receive an FDA-approved medication for a diagnosed opioid use disorder’.
• If any of the FDA-approved medication check box is checked then system displays 4b question: [IF YES] Has this client taken the medication as prescribed? And also displays additional CHILD questions with the following logic

With the selection of Methadone, System displays Specify how many DAYS of Methadone received (Required)

With the selection of Buprenorphine, System displays Specify how many DAYS Buprenorphine received (Required)

With the selection of Naltrexone, System displays Specify how many DAYS Naltrexone received (Required)

With the selection of Extended-release Naltrexone, System displays Specify how many DOSES Extended-release Naltrexone received (Required)

• Specify How Many DAYS data fields are numeric fields that accepts the number in the range 1-30.
• Specify How Many DOSES data fields are numeric data field that accepts the number in the range 1-2.

4b.  [IF YES] Has this client taken the medication as prescribed? (Optional)

Intent/Key Points

The intent is to record whether the client taken the medication as prescribed.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No

 

5. Has this client previously been diagnosed with an alcohol use disorder? (Optional)

Intent/Key Points

The intent is to record whether the client previously been diagnosed with an alcohol use disorder.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No

 

If ‘Yes’ is selected in above question then system displays following question:

 

5a. [IF YES] In the past 30 days, which FDA-approved medication did the client receive for the treatment of this alcohol use disorder? [CHECK ALL THAT APPLY.] (Optional)

Intent/Key Points

The intent is to record whether the client received FDA-approved medication for the treatment of the alcohol use disorder.

Answer Choice Definitions

SELECT the check box for the answer that best applies:

• Naltrexone
• Extended-release Naltrexone
• Disulfiram
• Acamprosate
• Client did not receive an FDA-approved medication for a diagnosed alcohol use disorder

Notes:

• If any of the FDA-approved medication is selected, then, you cannot select check box option ‘Client did not receive an FDA-approved medication for a diagnosed alcohol use disorder’.
• If any of the FDA-approved medication check box is checked then system displays 5b question: [IF YES] Has this client taken the medication as prescribed? And also displays additional CHILD questions with the following logic

With the selection of Naltrexone, System displays Specify how many DAYS of Naltrexone received (Required)

With the selection of Disulfiram, System displays Specify how many DAYS Disulfiram received (Required)

With the selection of Acamprosate, System displays Specify how many DAYS Acamprosate received (Required)

With the selection of Extended-release Naltrexone, System displays Specify how many DOSES Extended-release Naltrexone received (Required)

• Specify How Many DAYS data fields are numeric fields that accepts the number in the range 1-30.
• Specify How Many DOSES data fields are numeric data field that accepts the number in the range 1-2.

5b.  [IF YES] Has this client taken the medication as prescribed? (Optional)

Intent/Key Points

The intent is to record whether the client taken the medication as prescribed.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No

 

6. Has this client previously been diagnosed with a stimulant use disorder? (Optional)

Intent/Key Points

The intent is to record whether the client previously been diagnosed with a stimulant use disorder.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No

 

If ‘Yes’ is selected in above question then system displays following question:

 

6a. [IF YES] In the past 30 days, which intervention did the client receive for the treatment of this stimulant use disorder? [CHECK ALL THAT APPLY.] (Optional)

Intent/Key Points

The intent is to record whether the client received intervention for the treatment of the stimulant use disorder.

Answer Choice Definitions

SELECT the check box for the answer that best applies:

• Contingency Management
• Community Reinforcement
• Cognitive Behavioral Therapy
• Other evidence-based intervention
• Client did not receive any intervention for a stimulant use disorder. 

Notes:

• If any of the intervention is selected, then, you cannot select check box option ‘Client did not receive any intervention for a stimulant use disorder’.
• If any of the intervention check box is checked then system displays 5b question: [IF YES] Has this client attended and participated in interventions for stimulant use disorder? And also displays additional CHILD questions with the following logic

With the selection of Contingency Management, System displays Specify how many DAYS of Contingency Management received (Required)

With the selection of Community Reinforcement, System displays Specify how many DAYS Community Reinforcement received (Required)

With the selection of Cognitive Behavioral Therapy, System displays Specify how many DAYS Cognitive Behavioral Therapy received (Required)

With the selection of other evidence-based intervention, System displays Specify how many DAYS Other evidence-based intervention received (Required)

• Specify How Many DAYS data fields are numeric fields that accepts the number in the range 1-30.

6b.  [IF YES] Has this client attended and participated in interventions for stimulant use disorder? (Optional)

Intent/Key Points

The intent is to record whether the client attended and participated in interventions.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No

 

7. Has this client previously been diagnosed with a tobacco use disorder? (Optional)

Intent/Key Points

The intent is to record whether the client previously been diagnosed with a tobacco use disorder.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No

 

If ‘Yes’ is selected in above question, then system displays following question:

 

7a. [IF YES] In the past 30 days, which FDA-approved medication did the client receive for the treatment of this tobacco use disorder? [CHECK ALL THAT APPLY.] (Optional)

Intent/Key Points

The intent is to record whether the client received FDA-approved medication for the treatment of the tobacco use disorder.

Answer Choice Definitions

SELECT the check box for the answer that best applies:

• Nicotine Replacement
• Bupropion
• Varenicline
• Client did not receive an FDA-approved medication for a tobacco use disorder

Notes:

• If any of the FDA-approved medication is selected, then, you cannot select check box option ‘Client did not receive an FDA-approved medication for a tobacco use disorder’.
• If any of the FDA-approved medication check box is checked then system displays 7b question: [IF YES] Has this client taken the medication as prescribed? And also displays additional CHILD questions with the following logic.

With the selection of Nicotine Replacement, System displays Specify how many DAYS of Nicotine Replacement received (Required)

With the selection of Bupropion, System displays Specify how many DAYS Bupropion received (Required)

With the selection of Varenicline, System displays Specify how many DAYS Varenicline received (Required)

• Specify How Many DAYS data fields are numeric fields that accepts the number in the range 1-30.

7b.  [IF YES] Has this client taken the medication as prescribed? (Optional)

Intent/Key Points

The intent is to record whether the client taken the medication as prescribed.

Answer Choice Definitions

SELECT the radio button for the answer that best applies:

• Yes
• No     

Document Status (Required)

Answer Choice Definitions

• SELECT the appropriate Document Status drop-down:
  • Draft
  • Ready for Review
  • Closed Complete
  • Closed Incomplete

Document Status Date (System Generated)

This date represents the date of the Document Status.