Which of the following best describes your child’s current living situation?
RequiredotherB3
Narrative response
A prompt for a description, a selection or a short answer.
Answer categories: Your house or apartment | Your partner’s place | A friend or relative’s and paying rent | A friend or relative’s and not paying rent | Permanent housing program | Transitional housing program | Domestic violence shelter | Emergency shelter | Voucher hotel or motel | Hotel or motel you pay for | Residential drug or alcohol program | Jail or prison | Car or other vehicle | Abandoned building | Anywhere outside | Somewhere else [where]: ____ | Prefer not to answer | Thank you for completing this baseline form. | Public reporting burden for this collection of information is estimated to average 6 minutes per response. Send | comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance | Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 | Fishers Lane, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to | respond to, a collection of information unless it displays a currently valid Office of Management and Budget | (OMB) control number. The control number for this project is 0930-0400. | [OFFICE USE ONLY] RECORD MANAGEMENT – YOUNG CHILD / CAREGIVER / | BASELINE | CLIENT ID | | | | | | | | | | | | | SITE ID | | | | | | | | | | | | GRANT ID | | | | | | | | | | 1. Was this assessment conducted with the client/caregiver? | Yes – Client | Yes – Caregiver/Proxy | No | 1a. [IF QUESTION 1 IS YES] When? | | | | / | | | / | | | | | MM / DD / YYYY | 1b. [IF QUESTION 1 IS NO] Why not? Choose the primary reason. | Client/Caregiver was unable to provide consent | Client was not reached for assessment | Client no longer in care
- Instrument
- SUPRT-C
- Reporting
- baseline
- Target
- No target rule stated