TAP. Bright Yellow fields = required ISmart fields. You cannot move onto another screen if these are not filled in.

TAP The TAP (Treatment Assignment Protocol assessment instrument) module is used when a full assessments is needed for a client. There are 13 screens in the TAP module. You can do a TAP at the time of assessment (Intake TAP) and there is also an option of doing one at the time of admit (Follow up TAP.) For ASAC purposes we are not utilizing the Follow up TAP unless a TAP was needed at the time of evaluation but it was not done. Bright Yellow fields = required ISmart fields. You cannot move onto another screen if these are not filled in. Pale Yellow Fields= these are the SARS fields. These fields are required by the State and Federal government in order for us to get our funding. TAP - Client Profile screen: Interview Date: Primary Payment Source: Interviewer: Special Code: This is the date of the assessment/intake Refer to the Office Use Only box on the back of the client s Financial Form to get the primary payment source at time of evaluation. We do not every use 00-No Charge, 10-NA No Other Pay Source, or 99-Unknown. Staff giving the assessment/intake. Field can be left blank 1

Religious Preference: Field can be left blank How Long at Current Address: List the number in Years and Months that the client has lived at his current address. If the time period has not been any months then put a 0 in the Yrs box. Is the Residence Owned by You or Family: Answer Yes or No. Controlled Environment in Last 30 days: Choices here are; No, Jail, Alcohol/Drug Tx, Medical Tx, Psychiatric Tx or Other. Choose appropriate answer. How Many Days in Controlled Environment: If you answered No for the above question this field will be grayed out. If you did not answer No for the above question then fill in the amount of days the client spent in that controlled environment. Days Attended AA/NA/Similar Meetings in Last 30 Days: If the client has attended one of these types of groups on the last 30 days record the number of meetings they have attended. Days Waiting: This needs to be filled in with the client s waiting time to get in for this assessment session. This number is usually found in the appointment book. Months Since Discharged from Last Admission: If the client had been in substance abuse treatment before then list the number of months since there last discharge. If the client has never been admitted before then fill this box in with a 0. Is This a TAP for a Concerned Person: You would only answer Yes to this question if you are doing an assessment on a Concerned Person (someone here for treatment because a significant other or family member has alcohol or drug abuse issues. These clients are usually seen by our Family Therapists.) Admission Date: Leave this field blank Crisis Intervention Date: Leave this field blank. If there was a crisis session provided on this client prior to the TAP and this field is already filled in for you then leave that date in the field, otherwise leave this field blank. Placement Screening Date: Fill this in with the date of the assessment/intake. TAP - Withdrawal Screen: 1. What is the longest # of days in a row that you have gone without using alcohol and/or drugs: a. In the last 30 days? b. In the last 6 months? Explanation: Fill these two boxes in with a number. Question 1.a cannot be filled in with a number more than 30. Question 1.b cannot be filled in with a number more then 180. 2. Is the client reporting or exhibiting any of the following symptoms: Explanation: From the Withdrawal Symptoms box select any symptoms that the client is experiencing. You may select as many as you need that pertain to the client. Highlight (select) the symptom and use the right arrow button to move the symptom over to the Selected Withdrawal Symptoms box. 3. How many times in your life have you been treated for: a. Alcohol Abuse? b. Drug Abuse? 2

Explanation: Fill these boxes in with a number. If the client has not ever been treated before for either of those then enter in a 0. 4. How many of these were for: a. Alcohol detox only? b. Drug detox only? Explanation: This question is a continuation of question #3. Fill these boxes in with a number. If the question doesn t pertain to the client then enter in a 0. 5. How many days in the last 30 days have you been treated for alcohol and/or drugs as an: a. In-patient? b. Out-patient? Explanation: Fill these boxes in with a number. If the client has not been treated for either in the last 30 days then enter in a 0. 6. How many times in the last 30 days have you used: a. Alcohol? b. Drugs? Explanation: This question is tied into question #1, so if your answers don t coincide you will get an error message. Use the drop down box to choose the answer that best describes the client. Choose from the following: 1-2 Times per Week 1-3 Times per Month 2-3 Times Daily 3-6 Times per Week Daily More Than 3 Times Daily No Use in Past Month Unknown 7. How many days in the last 30 have you experienced: a. Alcohol Problems? b. Drug Problems? Explanation: Fill these boxes in with a number. If the client has not experienced any problems with one or both of these in the last 30 days enter in a 0. 8. How many times have you had: a. Alcohol DT s? b. A drug overdose? Explanation: Fill these boxes in with a number. If the client has not experienced one or both of these then enter in a 0. 9. Do you sometimes use prescription, over the counter medication, alcohol, or an illicit drug to relieve withdrawal symptoms? 10. Have you noticed the need to increase the amount you use to achieve the same effect or high, or sometimes feel less effect or high, after using your usual amount? 3

11. Would you say that you often use more then you initially intended to over a longer period of time? 12. Have you ever had blackouts while drinking or using; drank or used enough that you could not remember what you said or did the next day? 13. Would you say that you spend a great deal of time obtaining the substance(s) you use, using them, and/or recovering from their effects? 14. IV drug use in the past? Explanation: This box is grayed out and has already been filled in for you, the information was pulled from the Intake Transaction screen. 15. Do you currently use tobacco? Explanation: Fill in with the appropriate choice, which includes: 0-No Tobacco Use 1-Cigarettes 2-Cigars or Pipes 3-Smokeless Tobacco 4-Combo/more then 1 16. If Yes, indicate the daily amount? Explanation: This is a continuation of question #15. If you answered #15 with 0-No Tobacco Use, 2- Cigars or Pipes, 3-Smokeless Tobacco then this box will be grayed out and it will be filled in with No cigarette use. If you filled in #15 with either 1-Cigarettes or 4-Combo/more then 1 you will need to choose from the following: Less then ½ pack ½ to 1 pack 1 to 2 packs Greater then 2 packs 17. Would there be adequate support at home for you if you needed help while detoxing? 18. Do you have significant problems with other possible addictions such as sex, eating disorders, or gambling? Interviewer Rating: 19. How would you rate the client s need for detox treatment? Explanation: This is the counselor s opinion after going over the above questions with the client. Choose from the following: Critical -crucial; extremely important because of being or happening at a time of special difficulty, trouble, or danger, when matters could quickly get either worse or better. 4

High Moderate Low -above average; greater then the normal or average, e.g. in quantity, number, quality, intensity, or cast, or well above the smaller or lower level or amount. -average; neither particularly good nor particularly bad. -below average; below the average of expected degree, amount or intensity. -there is no problem at all. Notes Box: Use the notes box to indicate specifics about past treatment and about the client s use with in the past month (past 30 days.) Put any other information pertaining to the questions in the Withdrawal screen here. TAP Medical Screen: 1. How many times in your life have you been hospitalized for medical treatment? Explanation: Fill this box in with a number. If the client has not ever been hospitalized then fill this box in with a 0. 2. How long ago was your last hospitalization for a physical problem? Explanation: Fill in both the Yrs (years) and Mo (months) boxes with a number. If one or both boxes do not pertain to the client then fill one or both in with a 0. 3. Do you have a history of or current diagnosis of any of the following: Explanation: From the box on the left select any diagnosis that the client has. You may select as many as you need that pertain to the client. Highlight (select) the diagnosis and use the right arrow button to move the diagnosis over to the Selected Diagnosis box. Choose from the following: Abscess Arthritis Cardiac Cirrhosis or liver problems Diabetes Emphysema Fractures Gastrointestinal bleeding Hearing problems Hepatitis A Hepatitis B Hepatitis C Lung/breathing problems Pancreatitis Seizures Sexually transmitted disease Vision 4. Do you have chronic medical problems which continue to interfere with your life? 5. Are you taking any prescribed medication on a regular basis for a physical problem? If you choose Yes then the Please list: box will open up and you will need to list any medications prescribed to the client. This is for prescriptions for MEDICAL problems ONLY. There is a space in the next screen for drugs used for mental health issues. 6. How many days in the last 30 have you experienced medical problems? Explanation: Fill this box in with a number. If the client has not experienced any medical problems then enter in a 0. 5

7. How troubled have you been in the last 30 days by these medical problems? Explanation: This is a continuation of question #6. If you answered #6 with a 0 then this box is grayed out. If you put any other number in for question #6 then you need to choose from the following: -No problems or concerns Slightly -A little or somewhat troubled Moderately - A moderate extent or degree Considerably - Significantly; to a degree worth considering Extremely - Great severity. 8. How many times in the last 30 days have you visited the ER? Explanation: Fill this box in with a number. If the client has not visited the ER then enter in a 0. 9. Have you ever been diagnosis with TB? 10. Are you currently using birth control? 11. What is your current weight? Explanation: Fill this box in with a number. 12. Have you noticed a recent weight loss? 13. How many times in the last 6 months have you been hospitalized due to a non-tx drug and/or alcohol related problem? Explanation: Fill this box in with a number. If the client has not been hospitalized for this reason in the last 6 months then enter in a 0. Interviewer Rating: 14. How would you rate the client s need for medical treatment? Explanation: This is the counselor s opinion after going over the above questions with the client. Choose from the following: Critical High Moderate Low -crucial; extremely important because of being or happening at a time of special difficulty, trouble, or danger, when matters could quickly get either worse or better. -above average; greater then the normal or average, e.g. in quantity, number, quality, intensity, or cast, or well above the smaller or lower level or amount. -average; neither particularly good nor particularly bad. -below average; below the average of expected degree, amount or intensity. -there is no problem at all. Notes Box: Use the notes box for any other medical information/notes pertaining to the client s current medical conditions/concerns. TAP-Co-Occurring Screen: 6

1. How many times have you been treated for any psychological or emotional problems in a hospital or in-patient setting? Explanation: Fill this box in with a number. If the client has not been treated for any psychological or emotional problems then enter in a 0. Have you had a significant period, that was not a direct result of alcohol/drug use, in which you have: 2. Experienced serious depression, sadness, hopelessness, lack of interest? Explanation: For both Past 30 days or Lifetime select either Yes or No from the drop down box. 3. Experienced serious anxiety, tension, inability to relax, unreasonable worry? Explanation: For both Past 30 days or Lifetime select either Yes or No from the drop down box. 4. Experienced hallucinations or saw/heard things that did not exist? Explanation: For both Past 30 days or Lifetime select either Yes or No from the drop down box. 5. Experienced trouble understanding, concentrating, remembering? Explanation: For both Past 30 days or Lifetime select either Yes or No from the drop down box. 6. Experienced trouble controlling violent behavior including rage or violence? Explanation: For both Past 30 days or Lifetime select either Yes or No from the drop down box. 7. Experienced serious thoughts of suicide? Explanation: For both Past 30 days or Lifetime select either Yes or No from the drop down box. 8. Attempted suicide? Explanation: For both Past 30 days or Lifetime select either Yes or No from the drop down box. 9. Been prescribed meds for psychological or emotional problems? Explanation: For both Past 30 days or Lifetime select either Yes or No from the drop down box. If the client is on (or ever has been on) any medication for depression, anxiety, etc, then answer the appropriate question(s) with a Yes and this will open up the box Please specify:. In this box you need to enter the name of the medication, the daily amount and why the client is/was taking the medication. 10. How many days in the last 30 have you experienced psychological or emotional problems? Explanation: Fill this box in with a number. If the client has not experienced any psychological or emotional problems then enter in a 0. 11. How troubled have you been in the last 30 days by these emotional problems? Explanation: This is a continuation of question #10. If you answered #10 with a 0 then this box is grayed out. If you put any other number in for question #10 then you need to choose from the following: -No problems or concerns Slightly -A little or somewhat troubled Moderately - A moderate extent or degree Considerably - Significantly; to a degree worth considering Extremely - Great severity. 7

12. Psychiatric problem in addition to alcohol/drug problem? Interviewer Rating: At the time of the interview was the client: 13. Obviously withdrawn/depressed? 14. Obviously hostile? 15. Obviously anxious/nervous 16. Having trouble with reality testing, thought disorders, paranoid thinking? 17. Having trouble comprehending, concentrating, remembering? 18. Having suicidal thoughts? 19. How would you rate the client s need for treatment for emotional problems? Explanation: This is the counselor s opinion after going over the above questions with the client. Choose from the following: Critical High Moderate Low -crucial; extremely important because of being or happening at a time of special difficulty, trouble, or danger, when matters could quickly get either worse or better. -above average; greater then the normal or average, e.g. in quantity, number, quality, intensity, or cast, or well above the smaller or lower level or amount. -average; neither particularly good nor particularly bad. -below average; below the average of expected degree, amount or intensity. -there is no problem at all. Notes Box: Use the notes box for any other information pertaining to the client s psychological or emotional issues. TAP-Motivation Screen: 1. Is the client motivated to change his/her alcohol/drug use? 2. Are there any medical conditions which interfere with the client s treatment needs? If you answer Yes to this question it will open up the Please Specify box. List the medical conditions here that will interfere with the client s treatment needs. 8

3. How important now to the client is treatment for these medical problems? Explanation: If the client answered No to question #2 you can leave this question blank. If the client did answer Yes to question #2 then you will need to choose from the following: -No problems or concerns Slightly -A little or somewhat troubled Moderately - A moderate extent or degree Considerably - Significantly; to a degree worth considering Extremely - Great severity. 4. Are there any psychological conditions which interfere with the client s treatment needs? 5. How important now to the client is treatment for these psychological problems? Explanation: If the client answered No to question #4 you can leave this question blank. If the client did answer Yes to question #4 then you will need to choose from the following: -No problems or concerns Slightly -A little or somewhat troubled Moderately - A moderate extent or degree Considerably - Significantly; to a degree worth considering Extremely - Great severity. Interviewer Rating: 6. How would you rate the client s readiness to change? Pre-contemplation -Hasn t started considering it yet. No internal motivation. Not seeking services on their own. Contemplation -Considers something: to think about something seriously and at length, especially in order to understand it more fully. Determination -Firmness or purpose, will or intention Action -Doing something toward goal; the process of doing something in order to achieve a purpose. Maintenance -Continuation of something; the continuation or preservation of something unchanged or unimpaired. Relapsed -To recur, to worsen. Notes Box: Use the notes box for any other information pertaining to the client s motivation. TAP-Alcohol/Drug Usage 1. Which Substance do you consider to be the clients: a. Primary problem? b. Secondary problem? c. Tertiary problem? Explanation: Identify and enter the substances that contribute to the patient s dysfunction at time of evaluation. Up to three substances can be reported. The substance most responsible for the patient s dysfunction should be listed first. If it is clinically determined that the substances are contributing equally to the patient s impairment, they can be listed in any order. If there is no second or third substance involved, you may fill those in with 00-None. 9

Typically we do not list substances that the client has not used in the last 12 months, however in some circumstances you will. (I.e. - Client has been incarcerated for over 12 months, client was arrested for an OWI over 12 months ago but hasn t used since then you would still record the Primary problem as Alcohol.) Please note that you cannot recommend treatment for a client without having a Primary problem listed. If the client has not used in the last 12 months and you are not recommending treatment you may record the Primary problem as 00-None. You would use the Notes box at the bottom of the screen to record the client s previous use history. The following is a list of substances: 00-None 21- Alcohol 22- Cocaine/Crack 23-Marijuana/Hashish -Includes THC and any other cannabis sativa preparations 24- Heroin 25- Non Prescription Methadone 26- Other Opiates/Synthetics -Includes codeine, Dilaudid, morphine, Demerol, opium, and any other drug with morphine-like effects. 27- PCP -Phencyclidine 28- Other Hallucinogens -Includes LSD, DMT or STP 29- Methamphetamines 30- Other Amphetamines -Includes Benzedrine, Dexedrine, Preludin, Ritalin and any other amines and related drugs. 31- Other Stimulants 32- Benzodiazepines -Includes Diazepam, Fiurazepam, Chlordiazepoxide, Clorazepate, Lorazepam, Alprazolam, Oxazepam, Temazepam, Prazepam, Triazolam, Clonazepam and Halzepam. 33- Other Tranquilizers 34- Barbiturates -Includes Phenobarbital, Seconal, Nembutal, etc. 35- Other Sedatives/Hypnotics -Includes chloral hydrate, Placidyl, Doriden, etc. 36- Inhalants -Includes ether, glue, chloroform, nitrous oxide, gasoline, paint thinner, etc. 37- Over the Counter Medication -Includes aspirin, cough syrup, sominex, and any other legally obtained nonprescription medication. 38- Steroids 39- Ecstasy 48- Other 49- Oxycontin 50- Other Prescribed Analgesics 2. Was the substance prescribed to the client? a. Primary b. Secondary c. Tertiary Explanation: This question pertains to how you answered question #1 and the boxes are only open for the substances you listed. Your choices are Yes, No or NA. If the substance is not a prescribed substance (I.e. - Cocaine, Ecstasy, etc.) then you need to answer it with NA. If it is a substance that is prescribed but not for the client s use then you would answer this question with a No. 10

3. What was the age of first use? (If unknown, enter in 97 ; if not applicable, enter in 96 ): a. Primary b. Secondary c. Tertiary Explanation: The answer should be the age the client first used. This question pertains to how you answered question #1, if you entered 00-None for any of the problems the box is grayed out and a 96 was filled in for you. 4. What is the severity of use? a. Primary b. Secondary c. Tertiary Explanation: The level of severity is defined as the extent to which the use/abuse of the substance(s) has contributed to the patient s physical, mental, emotional or social dysfunction. This should be decided on between the counselor and the client but ultimately Clinical judgment will determine the level of severity for each substance listed if there is a difference of opinion. This question pertains to how you answered question #1, if you entered 00-None for any of the problems the box is grayed out and a NA was filled in for you. Your choices are: Mild problem/dysfunction -Not dangerous, not serious enough to endanger own life. Moderate problem/dysfunction -Average, not severe. Sever problem/dysfunction -Extremely bad or dangerous. NA -Not applicable. This is not to be used if a substance was listed in question #1. Not a problem -If there is only one substance listed and you enter this as the severity then you would not be recommending treatment for the client. 5. What is the frequency of use? a. Primary b. Secondary c. Tertiary Explanation: This question pertains to how you answered question #1, if you listed 00-None for any of the problems the box is grayed out and a NA was filled in for you. Select one of the following values to indicate the frequency of use during the 30 days prior to evaluation for each substance type recorded in question #1. 00 No Use in Past 6 Months 13 3-6 Times per Week 10 No Use in Past Month 14 Once Daily 11 1-3 Times in Past Month 15 2-3 Times Daily 12 1-2 Times per Week 16 More then 3 times daily 6. What are the methods of use? a. Primary b. Secondary c. Tertiary Explanation: Enter the appropriate code for the usual route of administration for each substance identified in question #1. If you listed 00-None for any of the problems the box is grayed out and a NA was filled in for you. 11

1-Oral 2-Smoking 3-Inhalant 8-Other 9-IV Injection 10-Nasal 11-Non IV Injection 7. Have you ever tried to reduce or control use of this substance? a. Primary b. Secondary c. Tertiary Explanation: If you listed 00-None for any of the problems in question #1 the box is grayed out. Your choices are Yes or No. 8. Has anyone ever asked you to stop using this substance? a. Primary b. Secondary c. Tertiary Explanation: If you listed 00-None for any of the problems in question #1 the box is grayed out. Your choices are Yes or No. 9. What was the date of last use? a. Primary b. Secondary c. Tertiary Explanation: If you listed 00-None for any of the problems in question #1 the box is grayed out. Enter the date of last use for the substances listed in question #1. If an exact date is not obtainable from the client use their best guesstimate. 10. Methadone Maintenance Planned? Explanation: This question should always be answered as No since ASAC does not administer Methadone. This does not mean that the client is not on Methadone. 11. Ever attended a self-help/support group (AA/NA, R/R, church, etc.)? Other Addictions box (NOTE: this question does not have a number beside it, it is located to the right of question #10 and #11.) Explanation: From the Other Addictions box choose all other addictions that apply to the client and use the right arrow button to move the selected items over to the Selected Other Addictions box. If the client does not have any other Addictions then choose 0-None. Your choices are: 0-None 3-Compulsive Disorder 4-Eating Disorder 5-Gambling 6-Other 12. Last substance admission environment in the last 10 years. Explanation: If the client has been admitted to treatment in the last 10 years you would select their last admission environment from the drop down box. If the client has never been admitted or only received a substance abuse evaluation then choose 00-No Previous Admission. 12

13. Number of prior substance abuse admission. Explanation: This is a continuation of question #12. If you filled that question in with 00-No Previous Admission then this box is grayed out and has a 0 filled in. If the client has been to treatment before list the number of times they have been in the last 10 years. Interviewer Rating: 14. How would you rate the client s potential for continued use? Explanation: This is the counselor s opinion after going over the client s substance abuse history with the client. Choose from the following: Critical -crucial; extremely important because of being or happening at a time of special difficulty, trouble, or danger, when matters could quickly get either worse or better. High -above average; greater then the normal or average, e.g. in quantity, number, quality, intensity, or cast, or well above the smaller or lower level or amount. Moderate -average; neither particularly good nor particularly bad. Low -below average; below the average of expected degree, amount or intensity. -there is no problem at all. Notes Box: Use the notes box for any other information pertaining to the client s substance use. In this box you will explain more of the problems listed in question #1. (I.e. - if they are using Alcohol, what are they drinking and how much? If they are using drugs, how much are they consuming and in what time frame?) You would also list any other substance use history or any other necessary information concerning the clients substance use. TAP-Support System/Employment 2. Training or technical ed? Explanation: Fill in both the Yrs (years) and Mo (months) boxes with a number. If one or both boxes do not pertain to the client then fill one or both in with a 0. This would be the amount of time the client has spent receiving training or technical education. 3. Do you have a profession, trade, or skill? If you answer Yes to this question it will open up the Please specify box. Fill that box in with the profession, trade or skill that the client has. Answer yes to this question even if the client did not have any formal training but has a profession, trade or skill. 4. Do you have a valid driver s license? 5. Do you have an automobile available for use? 6. Longest full time job? Explanation: Fill in both the Yrs (years) and Mo (months) boxes with a number. If one or both boxes do not pertain to the client then fill one or both in with a 0. This would be the amount of time the client has spent at his/her longest full time job. 13

7. Usual or last occupation? Explanation: Use the code that best describes the client s occupation. Your choices are: 0 None 4 Laborers, Not Farm 1 Prof./Managerial 5 Farm Owners/Laborers 2 Sales/Clerical 6 Service/Household 3 Crafts/Operatives 8. Does someone contribute to your support in any way? 9. Does this constitute the majority of your support? This is a continuation of question #8. 10. Employment status? Explanation: Use the code that best describes the client s employment status. Your choices are: E01 Employed Full Time -35 hours or more a week. Includes armed forces. E02 Employed Part Time -Less than 35 hours a week. E03 Unemployed (looking) -Looking for work in the past 30 days. NL01 Homemaker -No paid employment, primary home caretaker. NL02 Student -Client is a full time student. NL03 Retired -Left last job because of age. NL04 Person has a Disability -Unable to work because of disability. NL05 Inmate -Confined to jail or prison which restricts the client from securing employment. NL06 Unemployed (Not looking for work in the past 30 days) 11. Employer Explanation: If the client is employed (either full or part-time) fill in the employers name in this box. If the client is not employed you may leave this box empty. 12. How many days in the last 30 were you paid for work? (include under the table) Explanation: Fill this box in with a number. If the client was not paid for work in the last 30 days you would enter in a 0. (I.e. if the client works 5 days per week x 4 weeks = 20) How much money did you receive from the following resources in the last 30 days: 13. Employment (gross)? 14. Unemployment comp? 15. Welfare? 16. Pension, SS, benefits? 17. Mate, family, friends? 18. Illegal? *Current gross/taxable individual monthly income? Explanation: Fill in each field that pertains to the client with a number. If the client did not receive money in one of those categories you may leave it empty. For the question Current gross/taxable indivudal monthly income box you need to fill that in with a number, if the client did not have any please enter in a 0. These boxes pertain to the client only, do not record spouse, significant other or parental incomes. 14

19. What is your primary source of income? Explanation: Use the code that best describes the client s primary source of income. Your choices are: 00 None -Receives no income/support. 11 Wages/Salary -Full or Part-time employed. 12 Family/Friends -Dependent on family or friends. 13 Public Assistance -Social Welfare, ADC, Ward of the State, etc. 14 Retirement/Pension -Retirement pension or insurance. 15 Disability -Disability pension or insurance. 18 Other -Workers Compensation, Unemployment, and any other source. SSI/SSDI Never SSI/SSDI Previous SSI/SSDI Current SSI/SSDI Current and Previous 19a. Other Income Sources Explanation: From the Other Income Sources box choose all other sources that apply to the client and use the right arrow button to move the selected items over to the Other Income Sources Selected box. If the client does not have any other Addictions then choose 00-None. If the client answered question #8 with a Yes and question #9 with a No you should include that source here. Your choices are: 00-None 11-Wages/Salary 12-Family/Friends 13-Public Assistance 14-Retirement/Pension 15-Disability 18-Other SSI/SSDI Never SSI/SSDI Previous SSI/SSDI Current SSI/SSDI Current and Previous 20. How many months have you been employed during the last 6 months? Explanation: Fill this box in with a number. If the client was not employed in the last 6 months you would enter in a 0. 21. How many days in the last 30 have you experienced employment problems. Explanation: Fill this box in with a number. If the client did not experience any problems in the last 30 days you would enter in a 0. 22. How many days of work and/or school have you missed in the last 6 months due to substance abuse related problems? Explanation: Fill this box in with a number. If the client did not miss any days in the last 6 months you would enter in a 0. 23. Do you have current health insurance? Explanation: You can find the answer to this question in the Office Use Only box on the back of the client s Financial Form. Your choices are: Blue Cross/Blue Shield HMO Other Health Insurance HAWKI None Individual Policy 15

24. If yes, does it cover substance abuse treatment? Explanation: You can find the answer to this question in the Office Use Only box on the back of the client s Financial Form. Your choices are Yes or No. Interviewer Rating: 25. How would you rate the client s need for employment services? Explanation: This is the counselor s opinion after going over the client s employment history with the client. Choose from the following: Critical -crucial; extremely important because of being or happening at a time of special difficulty, trouble, or danger, when matters could quickly get either worse or better. High -above average; greater then the normal or average, e.g. in quantity, number, quality, intensity, or cast, or well above the smaller or lower level or amount. Moderate -average; neither particularly good nor particularly bad. Low -below average; below the average of expected degree, amount or intensity. -there is no problem at all. Notes Box: Place any other necessary comments that have to do with the client s employment history here. TAP- Support System /Social 1. What is your current relationship stats? Explanation: Use the code that best describes the client s current relationship status. Your choices are: 1 Single -Never married. Persons whose only marriage has been annulled are classified as single. 2 Married -Living with spouse. 3 Cohabitating -Living as married with any other individual. 4 Separated -Legally or otherwise absent from their spouse because of marital discord. 5 Divorced 6 Widowed 2. Are you satisfied with this situation? If you answer No to this question it will open up the If no, please specify box. Use this box to explain the reason why the client is not satisfied with their situation. 3. What has been your usual living arrangement? Explanation: Use the code that best describes the client s CURRENT living arrangement. Use the Notes section at the end of this screen to type in their usual living arrangement if the one you choose here is a temporary situation. (I.e. Client is currently living at the Hinzman Center but lives at home otherwise.) Your choices are: 11-Alone -One person household. 12-With parents -May be adult child. 13-Significant Other Only -Living with another significant person. 14-Significant Other And Child(ren) -Living with another significant person and child(ren). 16

15-With child(ren) Only 16-Other Adult(s) 17-Other Adult(s) and Child(ren) 18-Jail/Correctional Facility 19-Homeless 20-Correctional Halfway House 21-Hospital 22-Substance Abuse Halfway House 23-Group Home 24-Transitional Housing 25-Shelter 26-Child/Adolescent Foster Care 27-Juvenile Detention -Living with child(ren). -Living with any other person. -Living with any other person and child(ren). -Confined to jail or prison which restricts the client from securing employment. -No fixed address, includes shelters. -Living in a halfway house or group home setting. -Residing in a hospital. -This is a small, supervised residential facility in which residents typically participate in daily tasks. -This is temporary care in a home for a child or adolescent who has been removed from his/her home due to abuse or neglect. 4. How long have you lived in these arrangements? Explanation: Fill in both the Yrs (years) and Mo (months) boxes with a number. If one or both boxes do not pertain to the client then fill one or both in with a 0. This would be the amount of time the client has lived in the arrangements listed in question #3. 5. Are you satisfied with these arrangements? 6. Do you live with anyone who: a. Has a current alcohol problem? b. Uses non-prescribed drugs? 7. With whom do you spend most of your free time? Explanation: Your choices are Alone, Friends, or Family. 8. Are you satisfied spending your free time this way? Explanation: Your choices are Yes, No, or Indifferent. 9. How many friends do you have? Explanation: Fill this box in with a number. If the client does not have any friends enter in a 0. 10. List the people with whom you have had a close, long lasting relationship: Explanation: From the box on the left with all the choices, select the one s whom the client identifies as having a relationship with and use the right arrow button to move them over to the right box. Your choices are: Mother Father Brother/Sister Sexual Partner/Spouse Children Other Significant Family Close Friends Neighbors 17

Co-Workers 11. Have you had significant periods in the last 30 days or in your lifetime in which you have experienced serious problems getting along with your: Mother? Father? Brother/Sister? Sexual partner/spouse? Children? Other significant family? Close friends? Neighbors? Co-workers? Explanation: For both the Past 30 days and Lifetime columns your choices are Yes or No. If the client has not had issues or the question does not pertain to them enter in a No. 12. Have any of these people abused you? If so, how and when? (your choices are Emotionally, Physically or Sexually in either the Past 30 days or Lifetime.) Mother Other significant family Father Close friends Brother/Sister Neighbors Sexual partner/spouse Co-workers Children Explanation: For both the Past 30 days and Lifetime columns your choices are Yes or No. If the client has not had issues or the question does not pertain to them enter in a No. 13. How many children do you have age 17 or less (birth, adopted, or stepchildren) whether they live with your or not? Explanation: Fill this box in with a number. If the client does not have any children you would enter in a 0. 14. How many of these children spent the last 6 months living with you? Explanation: Fill this box in with a number. If the client has not had their children in the last 6 months you would enter in a 0. If you answered a 0 for question #13 then this box will be grayed out. 15. Are any of your children living with someone else because of a child protection order? If you answered a 0 for question #13 then this box will be grayed out. 16. Does your substance use cause problems at home with your partner, children, or home obligations? 17. Do you have a DHS case worker? 18. How troubled have you been in the last 30 days by: a. Family problems? 18

b. Social problems? Explanation: Your choices are: Slightly Moderately Considerably Extremely -No problems or concerns -A little or somewhat troubled - A moderate extent or degree - Significantly; to a degree worth considering - Great severity. 19. Have you given up or reduced your involvement in important social or recreational activities that did NOT include drinking or using? 20. Is there a family history of substance abuse or dependency? If you answer Yes to this question then in the Notes section at the end of this screen type in which family member it is any what their drug of choice was. Interviewer Rating: 21. How would you rate the client s need for family or social counseling? Explanation: This is the counselor s opinion after going over the client s social history with the client. Choose from the following: Critical High Moderate Low -crucial; extremely important because of being or happening at a time of special difficulty, trouble, or danger, when matters could quickly get either worse or better. -above average; greater then the normal or average, e.g. in quantity, number, quality, intensity, or cast, or well above the smaller or lower level or amount. -average; neither particularly good nor particularly bad. -below average; below the average of expected degree, amount or intensity. -there is no problem at all. Notes Box: Place any other necessary comments that have to do with the client s social history here. If the client does have children list their names, gender and DOB here. TAP- Support System /Legal 1. Was this admission prompted by the criminal justice system? 2. Are you on parole or probation? How many times have you been arrested and/or charged and/or convicted for the following? 3. Shoplifting/vandalism? 4. Parole/probation violation? 5. Drug Charges? 6. Forgery? 7. Weapons offense? 8. Burglary, larceny, B&E (breaking & entering)? 19

9. Robbery? 10. Assault? 11. Arson? 12. Rape? 13. Homicide/manslaughter? 14. Prostitution? 15. Contempt of court? 16. OWI in the last 12 months? 17. Non-drug or alcohol-related crime while under the influence in the last 12 months? 18. Non-drug or alcohol related crime while not under the influence in the last 12 months? 19. Drug or alcohol-related crime in the last 12 months? 20. Other? (use Other for Public Intox, OWI s, etc.) Explanation: Fill these boxes in with a number. For Questions 3 through 15 and Question 20- ask the client if they have ever been arrested in their lifetime. If the client has then enter the number of times arrested in the appropriate box. IF the client has been arrested before then ask them how many of those happened in the last 12 months. If the client HAS been arrested in the last 12 months then you would use Questions 16 through 19. Essentially Questions 16 through 19 should have been in their own section since they are really asking two separate things here; how many times has the client been arrested before in their life (and for what.) And then out of those arrests how many of them happened in the last 12 months (and what category). If the client has never been arrested for the choice listed then fill the Arrested box in with a 0 and then you may leave the Charged and Convicted box empty. If the client has been Charged or Convicted place the number of times in the appropriate box. (Charged= to formally be accused with a crime. Convicted= to find guilty of a crime as a result of legal proceedings.) For Questions 3 through 15 and Question 20: Add up the number of arrests in these boxes, This number would then be entered into the Placement Screening module of ISmart on the Legal Screen for the # of arrests in Lifetime question. 21. How many times have you been arrested in the past 12 months? Explanation: This box is grayed out and is filled in by the system. It comes from questions #16, 17, 18 and 19. 22. How many times have you been arrested in the past 30 days? Explanation: Fill this box in with a number. If the client has not been arrested in the past 30 days then enter in a 0. 23. How long were you incarcerated in your life? Explanation: Fill in both the Yrs (years), Mo (months) and Days boxes with a number. If one or all of the boxes do not pertain to the client then fill one or all in with a 0. This would be the total amount of time the client has spent incarcerated. If the client has had multiple incarcerations then you would total that up and enter in that amount. 24. How long was your last incarceration? Explanation: Fill in both the Yrs (years), Mo (months) and Days boxes with a number. If one or all of the boxes do not pertain to the client then fill one or all in with a 0. 20

25. What was it for? Explanation: This is a continuation of question #24. If you put in a number other then 0 for any of those boxes then you need to explain what the incarceration was for in the box. If the client has not been incarcerated you make leave this box empty. 26. Are you presently awaiting charges, trial, or sentence? 27. What for? Explanation: This is a continuation of question #26. If you answer it with a Yes then you need to explain what charges, trial or sentence the client is waiting for. 28. How many days in the last 30 were you detained or incarcerated? Explanation: Fill this box in with a number. If the client has not been detained or incarcerated in the last 30 days fill this in with a 0. 29. How many days in the last 30 have you engaged in illegal activities for profit? Explanation: Fill this box in with a number. If the client has not engaged in illegal activities in the last 30 days fill this in with a 0. 30. How serious do you feel your current legal problems are? Explanation: Your choices are: -No problems or concerns Slightly -A little or somewhat troubled Moderately - A moderate extent or degree Considerably - Significantly; to a degree worth considering Extremely - Great severity. Interviewer Rating: 31. How would you rate the client s need for legal services? Explanation: This is the counselor s opinion after going over the client s legal history with the client. Choose from the following: Critical High Moderate Low -crucial; extremely important because of being or happening at a time of special difficulty, trouble, or danger, when matters could quickly get either worse or better. -above average; greater then the normal or average, e.g. in quantity, number, quality, intensity, or cast, or well above the smaller or lower level or amount. -average; neither particularly good nor particularly bad. -below average; below the average of expected degree, amount or intensity. -there is no problem at all. Notes Box: Place any other necessary comments that have to do with the client s legal history here. If the client was arrested for an OWI you need to note the county of arrest here. TAP/ASAM See Appendix A for information on how to fill out the ASAM. 21

TAP/Summary 1. In your opinion, is the information in this assessment significantly distorted due to client s misrepresentation? Explanation: Your choices are: -No problems or concerns Slightly -A little or somewhat troubled Moderately - A moderate extent or degree Considerably - Significantly; to a degree worth considering Extremely - Great severity. 2. In your opinion, is the information in this assessment significantly distorted due to client s ability to understand? Explanation: Your choices are: -No problems or concerns Slightly -A little or somewhat troubled Moderately - A moderate extent or degree Considerably - Significantly; to a degree worth considering Extremely - Great severity. Comments Box: Explanation: Enter the following information into this box: Assessment Date: mm/dd/yyyy Test Results: (type here what the SASSI, MAST or other test score that was given to the client.) Placement Summary: (Summarize/draw conclusions based on info gathered, ASAM criteria, etc. on why you recommended the level of care you did. Also state what there is left to work on [I.e. lacks refusal skills, sexual abuse issues, etc.] You can state info here that you would not want the referral sources to see, but would be helpful for their counselor to read.) End Date: Explanation: Fill this in with the End date of the assessment; usually this is the same day as the assessment. If the assessment was done in two parts then the End date would be the last session. Total Interview Time: Explanation: Put the total length of time, in minutes, you spent with the client evaluation. The minutes are recorded in 15 minute increments. This should match the amount of time entered into your billable Encounter Note. TAP/Narrative This screen puts all the information entered into the TAP in a narrative form. ASAC usually does not use this screen. TAP/Diagnosis All clients need to have a diagnosis entered. See Appendix A for more information on Diagnosis. 22