Outcomes Follow-up
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1. Client Outcomes
*
1
. Date outcomes obtained?
MM
DD
YYYY
Enter date
Date outcomes obtained? Enter date Month
/
Day
/
Year
*
2
. Client MRN#
Client MRN#
*
3
. Gender?
Gender?
Male
Female
Transgender
*
4
. Age?
Age?
*
5
. Reason you came to ACER?
Reason you came to ACER?
Substance Abuse
Mental Health
Both
*
6
. Services you completed at ACER?
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
*
7
. ACER status?
ACER status?
Assessment
Transitioned to next level of care
Being discharged successfully
Being discharged unsuccessfully
6 month follow up
1 year follow up
*
8
. Employment Status?
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
9
. Current Living Situation?
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)
10
. Transportation?
Transportation?
Own vehicle
City transportation (bus, taxi, streetcar, etc.)
Rides from others
No transportation
Other
Other (please specify)
11
. Do you have a driver's license?
Do you have a driver's license?
Current license
License suspended
License revoked
Expired license
Never had license
Other
Other (please specify)
12
. Since starting at ACER, has your economic status changed?
(If you are a new client, skip this question)
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
13
. Legal Status?
Legal Status?
Charges Pending
Probation
Parole
Diversion Program
OCS monitoring
None
14
. In the past 30 days, have you been arrested for any of the following?
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)
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?
*
In the past 30 days, how often have you... 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)
16
. Are you currently seeing a psychiatrist or doctor for medication management for mental health concerns?
Are you currently seeing a psychiatrist or doctor for medication management for mental health concerns?
Yes
No
17
. In the past 30 days, have you been involved in any of the following outside of ACER?
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
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
*
How do you rate the current severity of the problems that brought you to ACER? Severity Rating No problem
Severity Rating Slight problem
Severity Rating Moderate problem
Severity Rating Severe problem
19
. How has your severity rating changed since your experience at ACER?
How has your severity rating changed since your experience at ACER?
No change/Stayed the same
Increased severity
Decreased severity
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