The Methadone Outpatient Forms include a comprehensive set of 14 intake, during-treatment, and follow-up data collection instruments for assessing client functioning and services in outpatient settings. An early version of the Intake Form was included in the Diagnostic Source Book on Drug Abuse Research and Treatment (1993) published by NIDA.
These forms have been updated conceptually and technically, however, as part of the more current TCU Core Forms. Interested users are strongly encouraged to consider a customized assessments approach based on selective “packaging” of the TCU Core Forms for intake and progress evaluations.
Initial Assessment is administered by the counselor and includes background and psychosocial information, a brief history of illegal drug use, and assessments of cocaine and alcohol dependency status based on DSM-IV criteria. [20 minutes]
- Initial Assessment [PDF; 31 KB; 9 pages] [DOC; 64 KB; 9 pages]
- Initial Assessment Answer Cards [PDF; 5 KB; 2 Answer Cards]
Urinalysis Report at Intake reports presence or absence of nine commonly used
illegal drugs.
- Urinalysis Report at Intake [PDF; 7 KB; 1 page] [DOC; 22 KB; 1 page]
Intake is administered by a counselor in a face-to-face interview held approximately one week after the Initial Assessment when the client has had time to reach greater stabilization and cognitive focus. [90 minutes]
- Intake [PDF; 831 KB; 32 pages] [DOC; 247 KB; 32 pages]
- Intake Answer Cards [PDF; 190 KB; 8 Answer Cards] [DOC; 52 KB; 8 Answer Cards]
It includes the following sections:
Part | Pages | |
---|---|---|
A: | Sociodemographic Background | 2-7 |
B: | Family Background | 8-10 |
C: | Peer Relations | 11-12 |
D: | Criminal History | 13-15 |
E: | Health and Psychological Status | 16 |
F: | Drug History | 17-26 |
G: | AIDS Risk Assessment | 27-29 |
H: | Interviewer Comments | 30-31 |
I: | Client Assessment Profile | 32 |
Self-Rating at Intake includes short scales for psychological adjustment (i.e.,self-esteem, depression, anxiety, and decision-making), social functioning (i.e.,childhood problems, hostility, risk-taking, and social conformity), and motivation scales (problem recognition, desire for help, treatment readiness, and external pressures). [approximately 15 minutes]
- Self-Rating at Intake [PDF; 17 KB; 6 pages] [DOC; 41 KB; 6 pages]
- Scoring Guide for Self-Rating at Intake [PDF; 15 KB; 4 pages]
Counseling Session Records
Counseling Session Record — Individual (Counselor) describes the length and type
of session as well as the issues addressed. [5 minutes]
- Counseling Session Record — Individual (Counselor)
[PDF; 18 KB; 2 pages] [DOC; 37 KB; 2 pages]
Counseling Session Record — Individual (Client) is a 5-item questionnaire eliciting the client’s reaction to the session. [2 minutes]
- Counseling Session Record — Individual (Client)
[PDF; 6 KB; 1 page] [DOC; 22 KB; 1 page]
Counseling Session Record — Group (Counselor) describes the length and type of session as well as the issues addressed. [5 minutes]
- Counseling Session Record — Group (Counselor)
[PDF; 15 KB; 4 pages] [DOC; 80 KB; 4 pages]
Counseling Session Record — Group (Client) is a 5-item questionnaire eliciting the client’s reaction to the session. [2 minutes]
- Counseling Session Record — Group (Client)
[PDF; 9 KB; 2 pages] [DOC; 52 KB; 2 pages]
During-Treatment Status is completed by the counselor in an individual session and re-assesses (for the previous 3-month period) major behavioral criteria such as employment, criminal involvement, drug use, and AIDS-risky behavior. Questions are a subset of the Intake Form. [25 minutes]
- During-Treatment Status [PDF; 64 KB; 16 pages] [DOC: 111 KB; 16 pages]
Evaluation of Self and Treatment (for the previous 3 months) records client ratings of the counselor and the program in general. It also contains scales assessing psychological adjustment, social functioning, and motivation. [25 minutes]
- Evaluation of Self and Treatment [PDF; 19 KB; 7 pages] [DOC; 41 KB; 7 pages]
- Scoring Guide for Evaluation of Self and Treatment [PDF; 13 KB; 3 pages]
Counselor Rating of Client is completed by the counselor for the purpose of describing client functioning and therapeutic strategies used in the preceding 3 months. [5 minutes]
- Counselor Rating of Client [PDF; 9 KB; 2 pages] [DOC; 28 KB; 2 pages]
Services Tracking Record (Monthly) serves as the overall monitoring record of client services and transactions, and is completed each month by agency staff. It contains information concerning counseling session attendance, medications prescribed, urinalyses results, and ancillary services provided. [Time to complete this form varies, depending on agency
record-keeping systems]
- Services Tracking Record [PDF; 11 KB; 2 pages] [DOC; 32 KB; 2 pages]
Discharge Report documents dates and reasons for leaving treatment.
[2 minutes]
- Discharge Report [PDF; 6 KB; 1 page] [DOC; 23 KB; 1 page]
Follow-up Interview is administered by a trained interviewer in a face-to-face session held at a designated time after discharge from treatment. It includes questions that are similar to the Intake Form, but also addresses functioning and outcome measures based on the posttreatment period. [90 minutes]
- Follow-up Interview [PDF; 96 KB; 26 pages] [DOC; 173 KB; 26 pages]
- Follow-up Answer Cards [PDF; 12 KB; 6 Answer Cards]
[DOC; 25 KB; 6 Answer Cards]
It includes the following sections:
Part | Pages | |
---|---|---|
A: | Sociodemographic Background | 2-6 |
B: | Family Background | 6-7 |
C: | Peer Relations | 8-10 |
D: | Criminal History | 10-12 |
E: | Health and Psychological Status | 12-13 |
F: | Drug History | 14-22 |
G: | Gambling | 22 |
H: | AIDS Risk Assessment | 23-25 |
I: | Interviewer Comments (to be completed after the interview) | 26 |