School SBIRT Data Tracking Sheet 2017-2018.xlsx
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Student InitialsGrade LevelStaff InitialsBuildingReferral SourceStart DateInitial GAIN-SS: Number of past month (3s) and past 2-12 months (2s) symptomsInitial TLFB 30 day frequency (# of days or times)Target Behavior or Substance (drop down menu)Follow Up GAIN-SS: Number of past month (1s) symptomsFollow Up TLFB 30 day frequency (# of days or times)# BI Sessions CompletedSelf-Assmt ave score (1-5) Referral made? 0 = no 1 = yesStudent entry into services? 0 = no 1 = yesComments
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MH-3s
MH-2s
BH-3s
BH-2s
AOD-3s
AOD-2s
C/V-3s
C/V-2s
MH-1sBH-1s
AOD-1s
C/V-1s
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16-other
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