Title : KK-tip7 9-05-01v2ph.qxd (Page 1) Description : Keywords : Author : ----------------------------------------------- KAP KEYS Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System CSAT’s Knowledge Application Program KAP Keys For Clinicians Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov ----------------------------------------------- KAP KEYS Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System These KAP Keys were developed to accompany the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. These KAP Keys are based entirely on TIP 7 and are designed to meet the needs of the busy clinician for concise, easily accessed "how-to" infor mation. For more information on the topics in these KAP Keys, readers are referred to TIP 7. Introduction TIP 25, Substance Abuse Treatment and Domestic Violence (1997) BKD139 TIP 26, Substance Abuse Among Older Adults (1998) BKD250 TIP 29, Substance Use Disorder Treatment for People with Physical and Cognitive Disabilities (1998) BKD288 TIP 32, Treatment of Adolescents With Substance Use Disorders (1999) BKD307 TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (1999) BKD342 Other Treatment Improvement Protocols (TIPs) that are relevant to these KAP Keys: ----------------------------------------------- Short Michigan Alcohol Screening Test 1 KAP KEYS Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System 1. Do you feel that you are a normal drinker? (By "nor mal" we mean that you drink less than or as much as most other people.) 2. Does your wife, husband, a parent, or other near rela tive ever worry or complain about your drinking? 3. Do you ever feel guilty about your drinking? 4. Do friends or relatives think you are a normal drinker? 5. Are you able to stop drinking when you want to? 6. Have you ever attended a meeting of Alcoholics Anonymous? 7. Has drinking ever created a problem between you and your wife, husband, parent, or other near relatives? 8. Have you ever gotten into trouble at work because of your drinking? 9. Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking? 10. Have you ever gone to anyone for help about your drinking? 11. Have you ever been in a hospital because of drink ing? 12.Have you ever been arrested for driving under the influence of alcoholic beverages? 13. Have you ever been arrested, even for a few hours, because of other drunken behavior? Answer Yes or No Continued on Back ----------------------------------------------- KAP KEYS Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Scoring Each "yes" answer equals one (1) point. A score of 1 or 2 indi cates there is no alcohol problem. A score of 3 indicates a bor derline alcohol problem. A score of 4 or more indicates an alcohol problem. ----------------------------------------------- Consent for the Release of Confidential Information: Criminal Justice System Referral 2 KAP KEYS Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System I, _____________________ , hereby consent to communication (Name of defendant) between _________________________________________ and (Treatment program) ____________________________________________________ (Court, probation, parole, and/or other referring agency) the following information: ______________________________ ____________________________________________________ (Nature of the information, as limited as possible) The purpose of and need for the disclosure is to inform the criminal justice agency(ies) listed above of my attendance and progress in treatment. The extent of information to be dis closed is my diagnosis, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program, prognosis, and ___________________ ____________________________________________________ ____________________________________________________ I understand that this consent will remain in effect and cannot be revoked by me until: _____ There has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment, or _____ _____________________________________________ (Other time when consent can be revoked and/or expires) I also understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations governing confi dentiality of substance abuse patient records and that recipi ents of this information may redisclose it only in connection with their official duties. ____________ ______________________________________ (Date) (Signature of defendant/patient) Prohibition on Redisclosing Information Concerning Substance Abuse Treatment Patients Once the consent form has been properly completed, there remains one last formal requirement. Any disclosure made with written patient consent must be accompanied by a written statement that the information being disclosed is protected by Federal law and that the person recieving the information can- Continued on Back ----------------------------------------------- KAP KEYS Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System not make any further disclosure of such information unless permitted by the regulations. This statement, not the consent form itself, should be delivered and explained to the recipient at the time of disclosure or earlier. The prohibition on redisclosure is clear and strict. Those who recieve the notice are prohibited from rereleasing information except as permitted by the regulations. (Of course, an offender may sign a consent form authorizing such a redisclosure.) See below for suggested statement language. This notice accompanies a disclosure of information con cerning a client in alcohol/drug abuse treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules pro hibit you from making any further disclosure of this informa tion unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as oth erwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT suffi cient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. ----------------------------------------------- Qualified Service Organization Agreement 3 XYZ Service Center ("the Center") and the _________________ _____________________________________________________ (Name of the program) ("the Program") hereby enter into a qualified service organiza tion agreement, whereby the Center agrees to provide the following: _____________________________________________________ _____________________________________________________ (Nature of services to be provided) Furthermore, the Center: 1. Acknowledges that in receiving, storing, processing, or other wise dealing with any information from the Program about the patients in the Program, it is fully bound by the provisions of the Federal regulations governing Confidentiality of Substance Abuse Patient Records, 42 CFR Part 2: and 2. Undertakes to resist in judicial proceedings any effort to obtain access to information pertaining to patients otherwise than as expressly provided for in the Federal confidentiality regulations, 42 CFR Part 2. Executed this ________ day of ________ , 200___ ___________________ ___________________ President Program Director XYZ Service Center (Name of Program) (Address) (Address) KAP KEYS Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System ----------------------------------------------- Glossary 4 Assessment: Evaluation or appraisal of a candidate's suitabili ty for substance abuse treatment modality/setting. This eval uation includes information regarding current and past use/abuse of drugs; justice system involvement; medical, familial, social, educational, military, employment, and treat ment histories; and risk for infectious diseases (e.g., sexually transmitted diseases, tuberculosis, HIV/AIDS, and hepatitis). Jail: To hold a person in lawful custody, usually while he or she is awaiting trial. In some jurisdictions, jails are used punitive ly for offenders serving short-term sentences or sentences to work release or weekends in jail. Jails range in size from rural jails having a dozen cells to urban jails having thou sands of cells. Parole: Process of being released from prison before the com pletion of a sentence. Parole involves supervision and other stipulations and prohibitions on certain activities imposed by a board of parole. Pre-release assessment: Infectious diseases risk assessment recommended for all potential parolees. This information should be available to the judge, prosecutor, and other par ticipants at the time of the pre-sentence hearing or trial/sen tencing. If the individual is paroled, this information should be conveyed to the parole officer for followup and evaluation. Recommendations for referral for treatment can be made at this time. Prison: Secure institution in which offenders are confined after sentencing for crimes. Prisons are classified as minimum, medium, or maximum security facilities, based on the need for internal institutional fortification. Inmates are similarly classified, by severity of offense and/or other behavior, and are usually assigned to prisons having a corresponding level of security. Probation: Sentence of community-based supervision. Probation includes stipulations and prohibitions on certain activities and often includes fines imposed by the court at the time of sentencing. Risk/needs assessment: Comprehensive report that includes the client's social, criminal, and other history. The report usu ally includes a recommendation for sentencing if the client is found guilty. KAP KEYS Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System ----------------------------------------------- Ordering Information TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in The Criminal Justice System Easy Ways to Obtain Free Copies of All TIP Products 1. Call SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889. 2. Visit CSAT's Website at www.csat.samhsa.gov Do not reproduce or distribute this publication for a fee with out specific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. DHHS Publication No. (SMA) 01-3556 Printed 2001