Follow Up by sdfgsg234

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									Follow Up
Client Name____________________________

1. Follow up demographics:
        Contact date: _______________

        Completion date: ____________

        Counselor: _________________

2. Follow up interview completed:
        Interview completed-----------------------------------------------Complete All
        Unable to locate client---------------------------------------------1-2
        Client refused interview-------------------------------------------1-2
        Other person refused-----------------------------------------------1-2
        Client incarcerated--------------------------------------------------1-2
        Other------------------------------------------------------------------1-2
    ________________________________________________________________________

3. County of residence: _____________                  10. Primary Income Source
                                                               None
4. Pregnant:         Yes     No                                Wages/Salary
                                                               Family/Friends
5. Living Arrangement:                                         Public Assistance
         Alone                                                 Retirement/Pension
        With parents                                           Disability
        With significant others                                Other
        With significant other & children                      SSI/SSDI Never
        With children alone                                    SSI/SSDI Previous
        Other adults                                           SSI/SSDI Current
        Other adult(s) and children                            SSI/SSDI Current and Previous
        Jail/Correctional Facility
        Homeless                                       11. Months employed since discharge from Treatment:
        Correctional Halfway House                         _______________
        Substance Abuse Halfway House
        Group Home                                     12. Days of work or school missed since discharge
        Hospital                                           from TX due to SA related problems:
        Transitional Housing                               ____________
        Shelter
        Child/Adolescent                               13. Client’s Monthly Gross: _____________
        Juvenile Detention
                                                       14. Times hospitalized since discharge from treatment
6. Marital Status                                          (due to a SA related problem): _________
       Never Married – Single
       Married                                         15. Times arrested since your discharge from treatment:
       Cohabitating
       Separated                                                  # of OWI since discharge from treatment?
       Divorced
       Widowed                                                   # of non-drug or alcohol-related crime while
       Unknown                                             under the influence since discharge from treatment
       Not Collected
                                                                 # of non-drug or alcohol-related crime while
7. Education (# of years): __________                      not under the influence since discharge from
                                                           treatment
8. Employment Status:
      Employed Full Time                                         # of drug or alcohol-related crimes since
      Employed Part Time                                   discharge from treatment
      Unemployed-Looking for Work
      Homemaker                                        16. # of arrests in the last 30 days: ___________
      Student
      Retired                                          17. # of days attended AA/NA or similar meetings per
      Person has disability                                month since discharge from treatment:
      Not in Labor Force                                   ___________
      Resident/Inmate
      Not in Labor Force-                              18. Substances Used
      Unemployed Not Seeking                               Primary:
                                                                  N/A
9. Occupation                                                     Alcohol
       None                                                       Cocaine/Crack
       Professional/Managerial                                    Marijuana/Hashish
       Sales                                                      Heroine
       Crafts/Operatives                                          Non Prescribed Methadone
                                                                  Other Opiates/Synthetics
       Laborers, Not Farm                                         PCP
       Farm Owners/Laborers                                       Other Hallucinogens
       Service/Household                                          Methamphetamines

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18. Primary (continued)                                   Inhalants
            Other Amphetamines                            Over-the-counter Meds
            Other Stimulants                              Steroids
            Benzodiazepines                               Ecstasy
            Other Tranquilizers                           Other
            Barbiturates                                  Oxycontin
            Other Sedatives/Hypnotics                     Other Prescribed Analgesics
            Inhalants                             Tertiary Frequency of Use:
            Over-the-counter Meds                         N/A
            Steroids                                      No Use in the past 6 months
            Ecstasy                                       No Use in the past month
            Other                                         1-3 times in the past month
            Oxycontin                                     1-2 times per week
            Other Prescribed Analgesics                   3-6 times per week
    Primary Frequency of Use:                             Once daily
            N/A                                           2-3 times daily
            No Use in the past 6 months                   More than 3 times daily
            No Use in the past month                      Unknown
            1-3 times in the past month
            1-2 times per week                19. In the client's opinion, how beneficial
            3-6 times per week                    was our counseling?
            Once daily                             Overall:
            2-3 times daily                                 Beneficial
            More than 3 times daily                         Do Not Know
            Unknown                                         Not Beneficial
    Secondary Substance Used:                               Very Beneficial
            N/A                                    Individual:
            Alcohol                                         Beneficial
            Cocaine/Crack                                   Did Not Receive
            Marijuana/Hashish                               Do Not Know
            Heroine                                         Not Beneficial
            Non Prescribed Methadone                        Very Beneficial
            Other Opiates/Synthetics               Family:
            PCP                                             Beneficial
            Other Hallucinogens                             Did Not Receive
            Methamphetamines                                Do Not Know
            Other Amphetamines                              Not Beneficial
            Other Stimulants                                Very Beneficial
            Benzodiazepines                        Group:
            Other Tranquilizers                             Beneficial
            Barbiturates                                    Did Not Receive
            Other Sedatives/Hypnotics                       Do Not Know
            Inhalants                                       Not Beneficial
            Over-the-counter Meds                           Very Beneficial
            Steroids                               Educational:
            Ecstasy                                         Beneficial
            Other                                           Did Not Receive
            Oxycontin                                       Do Not Know
            Other Prescribed Analgesics                     Not Beneficial
    Secondary Frequency of Use:                             Very Beneficial
            N/A
            No Use in the past 6 months       20. Follow up interview completed with:
            No Use in the past month                  Client
            1-3 times in the past month               Significant other
            1-2 times per week                        Other household member
            3-6 times per week                        Other
            Once daily
            2-3 times daily                   21. Have you been admitted to another alcohol/drug
            More than 3 times daily           agency since discharge from our agency?
            Unknown                                  Yes      No
    Tertiary Substance Used:
            N/A                               22. Follow up type of interview
            Alcohol                                    Letter or questionnaire
            Cocaine/Crack                              Telephone
            Marijuana/Hashish                          In person
            Heroine                                    IDPH
            Non Prescribed Methadone                   Other
            Other Opiates/Synthetics
            PCP                               23. Last substance abuse environment
            Other Hallucinogens                       Not Applicable (no tx recommended)
            Methamphetamines                          Medically managed detox
            Other Amphetamines                        Medically monitored detox
            Other Stimulants                          Medically managed intensive inpatient
            Benzodiazepines                           Clinically managed high intensity residential
            Other Tranquilizers                       Clinically managed medium intensity
            Barbiturates                               residential
            Other Sedatives/Hypnotics                 Day treatment/partial hospitalization


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23. (continued)
       Clinically managed low-intensity
        residential
       Continuing care
       Extended outpatient
       Intensive outpatient
       Outpatient detox
       Medically monitored intensive
        inpatient
       PMIC
       Assessment

24. Number of substance abuse admissions to
other agencies since discharge from our agency:
__________

25. Months since last discharge (if admitted to
another treatment program after discharge from
our program):
________________




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