Adult Services Outcome Tool Template
ADVERTISEMENT
1
2|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
:
Client STARS ID
Date: ______/_______/______
Survey Type: Initial or Interval
GAF Score: _______ (optional)
Adult Services Outcome Tool
1. Are you currently employed?
Don’t
1a. If employed,
Yes
No
Know
(Check all that apply)
Employed full time (35+ hours per week)
Are you paid at or above the minimum wage?
Are your wages paid directly to you by your
Employed part time
employer?
Unemployed, Looking for work
Could anyone have applied for this job?
Unemployed, Disabled
Do you have more than one job?
Unemployed, Volunteer Work
Unemployed, Retired
Unemployed, Not looking for work
Other (Specify) ________________________
Don’t Know
2. Are you currently enrolled in a school or a job training program?
Not enrolled
Other (Specify) ________________________
Don’t Know
Enrolled, full time
Enrolled, part time
2a. What is your highest educational level completed (12=GED or high school diploma)? ___________
3. How would you rate your overall health right now?
Don’t Know
Excellent
Very Good
Good
Fair
Poor
Don’t
Number of
4. In the past….
Nights/Times
Know
___
a. In the past 90 days how many nights have you been homeless?
___
b. In the past 90 days how many nights have you spent in a hospital for mental health care?
c. In the past 90 days how many nights have you spent in a facility for detox/inpatient or
___
residential substance abuse treatment?
d. In the past 90 days how many nights have you spent in correctional facility including jail, or
___
prison (as a result of an arrest, parole or probation violation)?
e. In the past 90 days how many times have you gone to an emergency room for a
___
psychiatric or emotional problem?
___
f. In the past 30 days how many times have you been arrested?
g. In the past 90 days how many days have you participated in inpatient treatment for
___
chemical abuse/dependency?
h. In the past 90 days how many times have you participated in AA, NA, Alanon, or
___
community based support groups?
4a. Which of the following best describes your current residential status?
Independent, living in private residence
Jail / Prison
Dependent, living in private residence
Foster Home / Foster Care
Residential care (group home, rehabilitation center, agency-operated care,…)
Crisis Residence
Institutional setting (24/7 care by skilled/specialized staff or doctors)
Other
Homeless (no fixed address)
|_|_|_|_|_|_|_|_|_|
:
Medicaid
Health Home Client
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
:
CID
Adult Services Outcome Tool v7. 3. 13 Draft
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business