SBIRT: Screening, Brief Intervention, and Referral to Treatment Presentation (graded)

Brief Negotiated Interview Checklist

INSTRUCTIONS: Please check either YES, NO, or N/A (not applicable), or score one number between 1 and 7, where applicable, for each of the following items.

Did the Provider… YES NO N/A 1) Ask patient for permission to discuss alcohol use and pause for their response?

2) Review patient’s drinking patterns and express concern? 3) Ask patient if he/she sees a connection between drinking and health care visit?

4) Make a specific connection between drinking and health care visit or other medical issue (e.g., MVC, GI complaints, hypertension)?

5) Inform patient about the exact NIAAA guidelines relevant to his/her sex and age group and tell patient his/her drinking is above guidelines and unsafe ?

6) Ask patient to select a number on the “Readiness Ruler”? 7) What was the number? (please write # in box) 8) Ask patient why he/she did not pick a lower number? 9) Ask patient: What would make his/her drinking a problem? OR Ask how important would it be for the patient to prevent that from happening? OR Discuss patient’s pros and cons of drinking?

10) Tell patient in a confrontational manner, that they have to cut down? 11) Make suggestions regarding how much patient should cut down? 12) Refer to patient as an “alcoholic” 13) Negotiate a drinking goal with the patient based on what patient has said by asking: What would you like to do?

14) Tell patient that if he/she can stay within NIAAA limits he/she will be less likely to experience (further) illness or injury related to alcohol use?

15) Provide a drinking agreement sheet? 16) Add his/her advice on the agreement? 17) Provide written information? 18) Encourage patient to schedule a follow-up appointment? 19) Thank patient for his/her time? 20) Offer confrontational warnings regarding drinking? 21) To what degree does the provider reflect patient’s motivational statements regarding cutting down? (please write # in box)

1 2 3 4 5 6 7 not at all somewhat extensively

22) Re-direct non-motivational statements? (please write # in box) 1 2 3 4 5 6 7

not at all somewhat extensively somewhat extensively