Outcomes Follow-up 1. Client Outcomes Question Title * 1. Date outcomes obtained? Enter date Date Question Title * 2. Client MRN# Question Title * 3. Gender? Male Female Transgender Question Title * 4. Age? Question Title * 5. Reason you came to ACER? Substance Abuse Mental Health Both Question Title * 6. Services you completed at ACER? Assessment Only Intensive Outpatient Program (IOP) Outpatient Opiate Detoxification Outpatient Substance Abuse Groups (OP) Individual Counseling Family Counseling Anger Management Maintenance Groups Substance Abuse Education Shoplifting Program Question Title * 7. ACER status? Assessment Transitioned to next level of care Being discharged successfully Being discharged unsuccessfully 6 month follow up 1 year follow up Question Title * 8. Employment Status? Retired Disabled Full-Time (35+ hrs/wk) Part-Time (below 35 hrs/wk) Homemaker Out of labor force and not looking for work Student Unemployed Question Title * 9. Current Living Situation? In an institution (jail, treamtent facility, hospital, etc.) Alone Alone with children With parents With roommates With spouse/significant other With spouse and children Transient/Couch-Surfing Other Other (please specify) Question Title * 10. Transportation? Own vehicle City transportation (bus, taxi, streetcar, etc.) Rides from others No transportation Other Other (please specify) Question Title * 11. Do you have a driver's license? Current license License suspended License revoked Expired license Never had license Other Other (please specify) Question Title * 12. Since starting at ACER, has your economic status changed?(If you are a new client, skip this question) Income has increased Income has stayed the same Income has decreased Question Title * 13. Legal Status? Charges Pending Probation Parole Diversion Program OCS monitoring None Question Title * 14. In the past 30 days, have you been arrested for any of the following? No Arrests DUI/DWI Possession Intent to Distribute Theft Breaking and Entering Domestic Violence Prostitution Manslaughter Public Intoxication Trespassing Rape Other Other (please specify) Question Title * 15. In the past 30 days, how often have you... Daily 4-5 times per week 2-3 times per week 1 time per week Every other week Once a month None Used alcohol? Used alcohol? Daily Used alcohol? 4-5 times per week Used alcohol? 2-3 times per week Used alcohol? 1 time per week Used alcohol? Every other week Used alcohol? Once a month Used alcohol? None Used other drugs? Used other drugs? Daily Used other drugs? 4-5 times per week Used other drugs? 2-3 times per week Used other drugs? 1 time per week Used other drugs? Every other week Used other drugs? Once a month Used other drugs? None Felt serious depression? Felt serious depression? Daily Felt serious depression? 4-5 times per week Felt serious depression? 2-3 times per week Felt serious depression? 1 time per week Felt serious depression? Every other week Felt serious depression? Once a month Felt serious depression? None Felt serious anxiety? Felt serious anxiety? Daily Felt serious anxiety? 4-5 times per week Felt serious anxiety? 2-3 times per week Felt serious anxiety? 1 time per week Felt serious anxiety? Every other week Felt serious anxiety? Once a month Felt serious anxiety? None Had serious thoughts of suicide? Had serious thoughts of suicide? Daily Had serious thoughts of suicide? 4-5 times per week Had serious thoughts of suicide? 2-3 times per week Had serious thoughts of suicide? 1 time per week Had serious thoughts of suicide? Every other week Had serious thoughts of suicide? Once a month Had serious thoughts of suicide? None Attempted suicide? Attempted suicide? Daily Attempted suicide? 4-5 times per week Attempted suicide? 2-3 times per week Attempted suicide? 1 time per week Attempted suicide? Every other week Attempted suicide? Once a month Attempted suicide? None Other serious mental health concerns? Other serious mental health concerns? Daily Other serious mental health concerns? 4-5 times per week Other serious mental health concerns? 2-3 times per week Other serious mental health concerns? 1 time per week Other serious mental health concerns? Every other week Other serious mental health concerns? Once a month Other serious mental health concerns? None Been to the ER for a medical emergency? Been to the ER for a medical emergency? Daily Been to the ER for a medical emergency? 4-5 times per week Been to the ER for a medical emergency? 2-3 times per week Been to the ER for a medical emergency? 1 time per week Been to the ER for a medical emergency? Every other week Been to the ER for a medical emergency? Once a month Been to the ER for a medical emergency? None Other (please specify) Question Title * 16. Are you currently seeing a psychiatrist or doctor for medication management for mental health concerns? Yes No Question Title * 17. In the past 30 days, have you been involved in any of the following outside of ACER? Individual Counseling Couples/Family Counseling Substance Abuse Treatment Program Outpatient Substance Abuse Treatment Program Inpatient Mental Health Treatment Program Outpatient Mental Health Treatment Program Inpatient 12 Step Meetings (AA, NA, CA, Alanon, Alateen, Celebrate Recovery, etc.) None of the above Question Title * 18. How do you rate the current severity of the problems that brought you to ACER? No problem Slight problem Moderate problem Severe problem Severity Rating Severity Rating No problem Severity Rating Slight problem Severity Rating Moderate problem Severity Rating Severe problem Question Title * 19. How has your severity rating changed since your experience at ACER? No change/Stayed the same Increased severity Decreased severity Done