Treatment Services Review
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1 Agency Name: ID #: {Module Name} Module Date: / / Treatment Services Review Site Name: Date: / / TSR #: Last TSR Date: / / Interviewer ID: 1. Have you been in treatment during the past 14 days? This means treatment at a program do not count AA/NA or other self-help groups. If NO (client not in treatment), go to question 8. No 0 Yes 1 2. Was your treatment at [NAME OF TREATMENT PROGRAM OF RECORD]? If NO, ask question 3. If YES, go to question 4. No 0 Yes 1 3. If in treatment but not at the treatment program of record, what was the name of your treatment program? Questions 4-7 refer to the treatment program that the client is attending. 4. How many days in the past 14 have you attended this treatment program? 5. Which of the following best describes the kind of program it was? Detox 1 Abst-oriented rehab 2 Dual disorder prog 3 Methadone maint 4 6. Did you stay overnight at the program? If YES, which of the following best describes that program? 7. If that program was an outpatient program, what were the recommended number of hours per week for that program? Inpatient hospital 1 Non-hospital residential 2 Recovery home/halfway house 3 Did not stay overnight -8 More than 20 hrs/wk hrs/wk hrs/wk 3 Less than 2 hrs/wk 4 Not an outpatient program What is your treatment status now? Out of treatment 1 On wait list 2 In treatment program of record 3 In a different treatment program 4 Comments: Page 1
2 Date: / / GENERAL INSTRUCTIONS FOR INTERVIEWERS: There are two sections in each of the problem areas with special definitions and instructions for each section. Review the manual for special circumstances. Specialized Services Section Specialized: group or individual sessions/services that focus upon a particular problem. More often than not, these services are provided by a specialist (e.g., vocational counselor, family therapist, psychiatrist). They are NOT general counseling sessions. We count only those services that the client actually received. For each question on the TSR, the interviewer asks whether the client received a particular service. If yes, the interviewer asks if the client received this service at the treatment program he/she currently attends (At-Program) or whether the client was referred to another program for this service (Out-Program). Note: Many programs operate satellite sites. If the client received a service at a satellite site of the treatment program he/she currently attends, this is counted as At-Program. General Counseling: group or individual sessions that focus on a range of problems or topics. Typically, these are the counseling sessions that the client receives at the treatment program he/she currently attends. Again, we count only those sessions that the client actually attended. Note: Sessions/services should be coded EITHER in the Specialized Services Section or the. Do not double count services/sessions. Page 2
3 Date: / / MEDICAL PROBLEM AREA 9. experienced significant physical medical problems? 10. been hospitalized for physical medical problems? Specialized Services: group or individual sessions/services that focused only on medical problem(s). How many times in the past 14 days have you received a: # At Prog # Out Prog 11. physical examination or a follow-up medical care visit? 12. medication prescription or refill for your physical medical problems? 13. session where you had your blood drawn for testing? If yes, were you tested for HIV? (0 = no, 1 = yes, -7 = don t know/won t say) 14. session devoted to medical education? AIDS or other disease prevention, etc. : can be group or individual sessions focused on a range of problems or topics. Typically sessions do not have a special agenda or title. 15. How many times in the past 14 days have you attended a general group or individual counseling session where there was a significant discussion regarding your medical problems? EMPLOYMENT AND SUPPORT PROBLEM AREA 16. been paid for working? 17. been in school or a training program? Specialized Services: group or individual sessions/services that focused only on employment/support problem(s). How many times in the past 14 days have you had a: # At Prog # Out Prog 18. meeting focused on helping you get housing, food, clothing or shelter? 19. meeting focused on helping you get SSI, welfare, disability/other benefits? 20. reading class, literacy testing or GED testing? 21. meeting focused on helping you get schooling or training? 22. meeting focused on helping you get employment? : can be group or individual sessions focused on a range of problems or topics. Typically sessions do not have a special agenda or title. How many times in the past 14 days have you had a general group or individual counseling session where there was a significant discussion regarding your: 23. food, clothing or shelter problems? 24. schooling, training or unemployment problems? Page 3
4 Date: / / ALCOHOL AND DRUG PROBLEM AREA 25. had at least one drink of alcohol? 26. had at least five drinks of alcohol? 27. used any illegal drug? 28. been in inpatient treatment for an alcohol or drug problem? Specialized Services: Answers should reflect the number of times sessions/services were provided. How many times in the past 14 days have you: # At Prog # Out Prog 29. actually taken medication to help you to detoxify from alcohol or drugs? 30. actually taken medication to prevent you from drinking or using drugs? 31. received acupuncture to stop or reduce your drinking or drug use? 32. received a session devoted to relapse triggers or methods of relapse prevention? 33. attended an AA/NA/CA or any other 12 step meeting? 34. How many times in the past 14 days have you had a general group or individual counseling session where there was a significant discussion regarding your alcohol/drug problems? ALCOHOL AND DRUG TESTING # At Prog # Out Prog 35. How many times have you had alcohol testing (e.g., breathalyzer) in the past 14 days? 36. How many of these tests said you had been drinking? 37. How many times have you had drug testing (e.g., urine screen) in the past 14 days? 38. How many of these tests said you had been using any drug? Page 4
5 Date: / / LEGAL PROBLEM AREA 39. been incarcerated? 40. engaged in any type of illegal activity for profit? Specialized Services: group or individual, session/services provided that focused only on legal problem(s). How many times in the past 14 days have you had a: # At Prog # Out Prog 41. meeting focused on your criminal charges or criminal problems? 42. meeting focused on your civil charges or civil legal problems? 43. How many times in the past 14 days have you had a general group or individual counseling session where there was a significant discussion regarding your criminal or civil legal problems? FAMILY RELATIONSHIPS PROBLEM AREA 44. had a significant argument with any adult member of your family? 45. had a significant argument with a child or adolescent in your family? 46. had any type of physical conflict or fight with any family member? Specialized Services: group or individual, session/services provided that focused only on family problem(s). How many times in the past 14 days have you had a: # At Prog # Out Prog 47. meeting focused on helping you with any problems getting along with your spouse/so and/or other members of your family? 48. meeting focused on helping you with any problems regaining contact with your spouse/so and/or other member of your family? 49. meeting focused on helping with any child care or parenting problems? How many times in the past 14 days have you had a general group or individual counseling session where there was a significant discussions regarding your: 50. adult family problems? 51. child care or parenting problems? Page 5
6 Date: / / PSYCHOLOGICAL PROBLEM AREA 52. experienced significant emotional problems (e.g., dep, anx, etc.)? 53. been hospitalized for an emotional or psychological problem? Specialized Services: group or individual, session/services provided that focused only on psychological problem(s). How many times in the past 14 days have you had: # At Prog # Out Prog 54. evaluation or testing for psychological or emotional problems? 55. a medication prescription or refill for any psychological or emotional problems? 56. a session of relaxation training, biofeedback, or meditation? 57. an individual psychotherapy session for any psychological or emotional problems? 58. a group psychotherapy session for any psychological or emotional problems? 59. How many times in the past 14 days have you had a general counseling session where there was a significant discussion regarding your psychological/emotional problems? Reference: McLellan AT ; Alterman AI ; Cacciloa J ; Metzger D ; O'Brien CP. A new measure of substance abuse treatment: Initial studies of the Treatment Service Review. J Nerv Ment Dis 180: , Page 6
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