Outcomes Follow-up

1. Client Outcomes

 
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1. Date outcomes obtained?
MM DD YYYY
Enter date
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2. Client MRN#
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3. Gender?
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4. Age?
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5. Reason you came to ACER?
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6. Services you completed at ACER?
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7. ACER status?
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8. Employment Status?
9. Current Living Situation?
10. Transportation?
11. Do you have a driver's license?
12. Since starting at ACER, has your economic status changed?
(If you are a new client, skip this question)
13. Legal Status?
14. In the past 30 days, have you been arrested for any of the following?
15. In the past 30 days, how often have you...
Daily4-5 times per week2-3 times per week1 time per weekEvery other weekOnce a monthNone
Used alcohol?
Used other drugs?
Felt serious depression?
Felt serious anxiety?
Had serious thoughts of suicide?
Attempted suicide?
Other serious mental health concerns?
Been to the ER for a medical emergency?
16. Are you currently seeing a psychiatrist or doctor for medication management for mental health concerns?
17. In the past 30 days, have you been involved in any of the following outside of ACER?
18. How do you rate the current severity of the problems that brought you to ACER?
No problemSlight problemModerate problemSevere problem
Severity Rating
19. How has your severity rating changed since your experience at ACER?