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pdfA1-1
ATTACHMENT A-1:
INSTRUMENTS FOR MOTHERS
A-1.1
Brief Infant Toddler Social and Emotional Assessment
A-1.2
Child Data Collection Tool
A-1.3
Parenting Relationship Questionnaire
A-1.4
Parenting Stress Index
A-1.5
Social Skills Improvement System
A-1.6
Trauma Symptom Checklist for Young Children
A-1.7
BASIS-24®
A-1.8
Child Abuse Potential Inventory
A-1.9
Family Support Scale
A-1.10
Ferrans and Powers Quality of Life Index (for women)
A-1.11
Items Administered to Women
A-1.12
Site Visit Protocol-Client Focus Group
A1-2
Attachment A-1.1
Brief Infant Toddler Social and Emotional Assessment (BITSEA)
A1-3
BRIEF INFANT TODDLER SOCIAL AND EMOTIONAL ASSESSMENT (BITSEA)
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:
Form Approved
OMB No. XXXX-XXXX
Expiration Date XX-XX-XXXX
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
CHILD’S ID# |__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE: Intake |__|
3-mos post-Intake |__|
PERSON COMPLETING |_______________|
6-mos post-Intake |__|
GRANT#
Discharge |__| 6-mos post-Discharge |__|
TI |__|__|__|__|__|__|
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A1-5
A1-6
A1-7
A1-8
Attachment A-1.2
Child Data Collection Tool
A1-9
FEBRUARY 23, 2010 FORMAT
Readmit |__|
Initial |__|__|
DATE:
|__|__| |__|__| |__|__|__|__|
2 0
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Form Approved
OMB No. xxxx-xxxx
Expiration Date xx-xx-xxxx
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
CHILD’S ID# |__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE:
Intake |__|
Delivery |__|
PERSON COMPLETING |_______________|
GRANT#
TI|__|__|__|__|__|__|
CHILD DATA COLLECTION TOOL
The following two items (A1 and A2) only need to be administered once to each mother.
Please check here if they have already been administered. (If unknown, please readminister.) ........
A1.
How many children do you have?
|__|__| ...................................................................................................
None .....................................................................................................
A2.
Please list the ages of all of your children. (READ IF NECESSARY: If a child is deceased, please list the age at
death.)
CHILD AGE (If child < 1 year old, write ‘00’)
|__|__| years
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
|__|__| years .........................................................................................
N/A – No children ..................................................................................
Instructions: This demographic information is to be obtained during the first 30 days of intake (or delivery) and is focused on the
background of a single child. This information is to be completed on each child receiving treatment services both onsite and offsite.
This tool consists of Part 1 to be completed by a children’s specialist through interviewing the mother; and Part 2 to be
completed by a health care professional through interviewing the mother and reviewing the medical records.
Public reporting burden for this collection of information is estimated to average 45 minutes per response; including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1044, 1
Choke Cherry Road, 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 OMB control number. The control number for this project is 0930-0269.
A1-10
PART 1. BIOLOGICAL BACKGROUND
1.
Age
2.
Gender
|__|__| YEARS
Male ......................................................................................................
Female ..................................................................................................
3.
Ethnic/Racial Identification (Complete both race and ethnicity items.)
Ethnicity
Hispanic or Latino .................................................................................
Not Hispanic or Latino ...........................................................................
Race (Select all that apply.)
Black or African American .....................................................................
Alaska Native ........................................................................................
American Indian ....................................................................................
Asian .....................................................................................................
Native Hawaiian or Other Pacific Islander ............................................
White .....................................................................................................
No response provided ...........................................................................
4.
What is the formal relationship of this child to the mother, with whom he/she has been admitted for receiving
treatment services?
Biological...............................................................................................
Step ......................................................................................................
Adopted.................................................................................................
Grandmother .........................................................................................
Aunt ......................................................................................................
Foster....................................................................................................
Other .....................................................................................................
5.
Is the biological father still alive?
Yes........................................................................................................
No ........................................................................................................
Don’t Know (but know who he is) .........................................................
Don’t know who he is ............................................................................
6.
Is English the first and primary language spoken by this child?
Yes ........................................................................................................
No .........................................................................................................
N/A ........................................................................................................
7.
Does this child have any of the following intelligence-related challenges? (Select all that apply.)
Mental retardation .................................................................................
Down Syndrome ...................................................................................
Autistic Spectrum Disorders ..................................................................
None of the above.................................................................................
UNKNOWN ...........................................................................................
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8.
Does this child have any of the following physical challenges? (Select all that apply.)
Blindness ..............................................................................................
Deafness ...............................................................................................
Cerebral Palsy ......................................................................................
Inability to be Mobile (Handicapped) .....................................................
Muscular Dystrophy ..............................................................................
Facial Disfigurement .............................................................................
Other (specify) ___________________________________________
None of the above.................................................................................
9.
Does this child have siblings? Include full, step, half, and adoptive siblings.
Yes ........................................................................................................
No .........................................................................................................
10.
GO TO Q10
What is this child’s placement amongst his/her siblings?
Oldest child ...........................................................................................
Youngest child ......................................................................................
Middle child ...........................................................................................
UNSURE - TOO MANY TO DETERMINE.............................................
N/A - AN ONLY CHILD WITH NO SIBLINGS .......................................
SOCIO-ECONOMIC BACKGROUND
11.
In the past year – prior to admission – with whom did this child live the most?
Both biological father and mother .........................................................
Biological mother ..................................................................................
Biological father ....................................................................................
Biological grandparents (on the mother’s side) .....................................
Biological grandparents (on the father’s side) .......................................
Biological aunt or uncle (on the mother’s side) .....................................
Biological aunt or uncle (on the father’s side) .......................................
Foster care parents ...............................................................................
Adoptive parents ...................................................................................
Friends of the family..............................................................................
UNKNOWN ...........................................................................................
12.
If this child was living with someone other than the biological mother, was this a formal placement arranged by a
Child Welfare System?
Yes ........................................................................................................
No .........................................................................................................
N/A ........................................................................................................
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13.
Who has legal custody of this child?
Both biological father and mother together ...........................................
Biological mother ..................................................................................
Biological father ....................................................................................
Biological grandparents (on the mother’s side) .....................................
Biological grandparents (on the father’s side) .......................................
Biological aunt or uncle (on the mother’s side) .....................................
Biological aunt or uncle (on the father’s side) .......................................
Adoptive parents ...................................................................................
State (Child welfare or foster care) .......................................................
Other (specify) __________________________________________
14.
In the past year – prior to admission – how many months has this child ever been homeless (living on the streets,
living in a homeless shelter, sleeping in empty buildings, etc.)?
0 months ...............................................................................................
1 to 3 months .......................................................................................
4 to 6 months ........................................................................................
7 to 9 months ........................................................................................
10 to 12 months ....................................................................................
15.
Where does this child’s main source of income or financial support come from?
Both biological father and mother .........................................................
Child support from biological father only ...............................................
Biological mother only, through earned income ....................................
Biological father and spouse/domestic partner .....................................
Biological mother’s spouse/domestic partner........................................
State/Public Assistance (SSDI – social security disability insurance;
WIC – women, infants, and children’s program; TANF –
temporary assistance to needy families; EMI – emergency
child insurance) .................................................................................
Legally appointed guardian ...................................................................
Members of the family...........................................................................
Friends of the family..............................................................................
Nonlegal income ...................................................................................
Other (specify) __________________________________________
16.
Where does this child’s main source of health care coverage/insurance come from?
Biological parents’ health insurance .....................................................
Biological grandparents’ health insurance ............................................
Legal guardians’ health insurance ........................................................
State/Public Assistance (Medicaid).......................................................
Federal Assistance (Indian Health Service, VA, etc.) ...........................
Nowhere – doesn’t have any ...............................................................
17.
In the past 2 years, how many different states has this child lived in?
One .......................................................................................................
Two .......................................................................................................
Three ....................................................................................................
Four ......................................................................................................
Five .......................................................................................................
More than five .......................................................................................
4
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18.
In the past 2 years, how many different neighborhoods has this child lived in?
One .......................................................................................................
Two .......................................................................................................
Three ....................................................................................................
Four ......................................................................................................
Five .......................................................................................................
More than five .......................................................................................
19.
What type of structure has this child lived in most of his/her life?
House ...................................................................................................
Apartment .............................................................................................
Trailer Home .........................................................................................
This Facility ...........................................................................................
Hospital .................................................................................................
Other (specify) ___________________________________________
LEGAL BACKGROUND
20.
To your knowledge, how many Child Protective Services (CPS) abuse reports have ever been made on this child,
even if they were not substantiated (founded)?
None .....................................................................................................
One .......................................................................................................
Two .......................................................................................................
Three ....................................................................................................
Four ......................................................................................................
Five .......................................................................................................
More than five .......................................................................................
Don’t Know ...........................................................................................
21.
To your knowledge, how many CPS neglect reports have ever been made on this child, even if they were not
substantiated (founded)?
None .....................................................................................................
One .......................................................................................................
Two .......................................................................................................
Three ....................................................................................................
Four ......................................................................................................
Five .......................................................................................................
More than five .......................................................................................
Don’t Know ...........................................................................................
22.
Has this child ever been removed from anyone’s care by CPS?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
5
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23.
How many times has this child been removed from your care by CPS?
None .....................................................................................................
One time ...............................................................................................
Two times .............................................................................................
Three times ...........................................................................................
Four times .............................................................................................
Five times .............................................................................................
More than five times..............................................................................
Don’t Know ...........................................................................................
23a.
For how many total months has this child been removed from your care by CPS?
Less than 1 month ..................................................................
1 to 3 months ..........................................................................
4 to 6 months ..........................................................................
7 to 12 months ........................................................................
13 to 24 months ......................................................................
25 to 36 months ......................................................................
37 to 48 months ......................................................................
More than 48 months..............................................................
Don’t Know .............................................................................
N/A..........................................................................................
23b.
24.
Which of the following caused removal of this child by CPS? (Select all that apply.)
Child abuse (physical) ............................................................
Child abuse (neglect)..............................................................
Child abuse (sexual) ...............................................................
Child abuse (emotional/mental) ..............................................
Involvement of child in illegal activities ...................................
Child found to be under the influence of alcohol and/or
other drugs .............................................................................
Other (specify) ___________________________________
Don’t Know .............................................................................
N/A..........................................................................................
Has this child ever been involved with the criminal or Juvenile Justice System (been referred, detained or arrested
for: breaking the law, truancy, running away, violating curfews, drug using or selling, etc.)?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
25.
At what age did this child’s involvement with the criminal or Juvenile Justice System begin?
None, not ever involved ........................................................................
1 month to 5 years ................................................................................
6 to 10 years .........................................................................................
11 to 14 years .......................................................................................
15 to 17 years .......................................................................................
6
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26.
How many times has this child been involved with the criminal or Juvenile Justice System?
None .....................................................................................................
One time ...............................................................................................
Two times .............................................................................................
Three times ...........................................................................................
Four times .............................................................................................
Five times .............................................................................................
More than five times..............................................................................
27.
How many months has this child been legally detained?
None .....................................................................................................
Less than 1 month ................................................................................
1 to 3 months ........................................................................................
4 to 6 months ........................................................................................
7 to 12 months ......................................................................................
13 to 24 months ....................................................................................
25 to 36 months ....................................................................................
37 to 48 months ....................................................................................
More than 48 months ............................................................................
28.
Has this child ever been involved with gangs (belonged to a gang or associated with gang members)?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
29.
Has this child ever witnessed acts of violence in his/her home, community, or school?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
30.
Has this child ever been exposed to trauma (e.g. drive by shootings, school shootings, fights) in his/her home,
community, or school?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
31.
Has this child ever been a victim of violence? (Select all that apply.)
Yes (in the home)..................................................................................
Yes (at school) ......................................................................................
Yes (in the neighborhood) .....................................................................
Yes (by an animal) ................................................................................
No .........................................................................................................
Don’t Know............................................................................................
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32.
Has this child ever committed any acts of violence against animals?
Yes (without weapons)..........................................................................
Yes (with weapons) ..............................................................................
Yes (both with and without weapons) ...................................................
No .........................................................................................................
Don’t Know ..........................................................................................
33.
Has this child ever committed any acts of violence against humans?
Yes (without weapons)..........................................................................
Yes (with weapons) ..............................................................................
Yes (both with and without weapons) ...................................................
No .........................................................................................................
Don’t Know ..........................................................................................
34.
Has this child ever set fires?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
EDUCATIONAL BACKGROUND
35.
Which of the following educational levels is this child in? (Please circle only one response.)
Day Care only .......................................................................................
Preschool ..............................................................................................
Kindergarten .........................................................................................
Grade 1 ─ 5 ..........................................................................................
Grade 6 ─ 8 ..........................................................................................
Grade 9 ─ 12 ........................................................................................
None .....................................................................................................
Don’t Know ...........................................................................................
36.
Is this child at the appropriate educational level for his/her age?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
N/A ........................................................................................................
37.
Has this child ever been held back in school?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
N/A ........................................................................................................
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38.
If this child is in school, is his/her progress in school reflective of him/her being an…?
‘A’ student, ............................................................................................
‘B’ student, ............................................................................................
‘A & B’ student, .....................................................................................
‘C’ student, ............................................................................................
‘D’ student, or........................................................................................
‘F’ student? ...........................................................................................
Don’t Know ...........................................................................................
N/A ........................................................................................................
39.
If this child is in school, indicate what type of attendance pattern this child has in school.
Poor (misses a lot of days) ...................................................................
Fair (misses some days) .......................................................................
Good (misses only a few days) .............................................................
Excellent (goes consistently) ................................................................
Don’t Know ..........................................................................................
N/A ........................................................................................................
40.
Which of the following extracurricular activities does this child participate in? (Select all that apply.)
Sports ...................................................................................................
Music ....................................................................................................
Dance ...................................................................................................
Drama ...................................................................................................
Community Service ...............................................................................
Religious Activities ................................................................................
None .....................................................................................................
N/A ........................................................................................................
Other (specify) ___________________________________________
41.
Has this child been assessed for any possible learning disabilities?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
42.
Has this child been diagnosed with a learning disability?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
43.
Has this child ever received Ritalin or any other prescription medication for attention deficit disorder (ADD) or
attention deficit and hyperactivity disorder (ADHD)?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
N/A ........................................................................................................
9
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SPIRITUAL BACKGROUND
44.
How often does this child attend religious services?
Once a week .........................................................................................
Once a month .......................................................................................
Four times a year ..................................................................................
During holidays .....................................................................................
Twice a year .........................................................................................
Once a year ..........................................................................................
Not at all................................................................................................
45.
How often does this child experience prayer, either by doing it himself/herself or with someone else?
Every day/night .....................................................................................
Few times a week .................................................................................
Once a week .........................................................................................
Once a month .......................................................................................
Few times a year ..................................................................................
Only at holiday ceremonies...................................................................
Only to bless a meal .............................................................................
Not at all................................................................................................
46.
Which of the following spiritual activities does this child experience most?
Reading or being read to from inspirational sources.............................
Listening to relaxation/ inspirational music............................................
Listening to stories ................................................................................
Finding a quiet spot ..............................................................................
Taking nature/environmental appreciation walks ..................................
Other (specify) ___________________________________________
None at all ............................................................................................
47.
Does this child believe in a ‘Higher Power’ of any kind?
Yes ........................................................................................................
No .........................................................................................................
DON’T KNOW .......................................................................................
N/A (TOO YOUNG)...............................................................................
10
A1-19
RECREATION/LEISURE BACKGROUND
Yes
No
Don’t Know
48. Has this child gone to museums or other historical sites of any
kind?...............................................................................................
49. Has this child played in any community/neighborhood team/group
sports? ...........................................................................................
50. Has this child ever been to an amusement park or local carnivals or
fairs? ..............................................................................................
51. Has this child ever been on any picnics (family, community,
church, school)? ...........................................................................
52. Does this child go to arcades or a friend’s home to play games?
53. Does this child play video games at home? ...............................
54. Does this child watch television at home? .................................
55. Does this child participate in family games, such as cards,
checkers, or Backgammon? ........................................................
56. Does this child go out to the movies?.........................................
57. Does this child have hobbies, such as arts and crafts or reading?
58. Does this child have access to the Internet outside of school?
59. Does this child go to the community library to read, check out
books, or participate in any programs?
BACKGROUND OF PARENTAL RELATIONSHIPS
60.
How would you describe your efforts at initiating involvement in this child’s life?
No effort at all .......................................................................................
Efforts are not good .............................................................................
Efforts are good ....................................................................................
Efforts are very good.............................................................................
Efforts are excellent ..............................................................................
Don’t Know ...........................................................................................
11
N/A
A1-20
61.
How would you describe the biological father’s efforts at initiating involvement in this child’s life?
No effort at all .......................................................................................
Efforts are not good .............................................................................
Efforts are good ....................................................................................
Efforts are very good.............................................................................
Efforts are excellent ..............................................................................
Don’t Know ...........................................................................................
N/A ........................................................................................................
62.
If this child’s biological mother does not live with him/her, which of the additional ways is there involvement in
his/her life? (Select all that apply.)
Monetary support ..................................................................................
Child care ..............................................................................................
Visits on a regular basis ........................................................................
Visits on an irregular basis ....................................................................
Telephone contact ................................................................................
Letters in the mail..................................................................................
Other (specify) ___________________________________________
None ....................................................................................................
N/A ........................................................................................................
63.
If this child’s biological father does not live with him/her, which of the additional ways is there involvement in his/her
life? (Select all that apply.)
Monetary support ..................................................................................
Child care ..............................................................................................
Visits on a regular basis ........................................................................
Visits on an irregular basis ....................................................................
Telephone contact ................................................................................
Letters in the mail..................................................................................
Other (specify) ___________________________________________
None ....................................................................................................
N/A ........................................................................................................
64.
Do you believe it is appropriate for this child to have contact with his/her biological father?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
N/A ........................................................................................................
65.
Did this child’s biological father accompany his/her mother to prenatal visits?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
N/A ........................................................................................................
66.
Was this child’s biological father present at his/her birth?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
N/A ........................................................................................................
12
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67.
Is this child’s biological father a substance abuser?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
N/A ........................................................................................................
68.
If this child has no contact with his/her biological mother, which of the following persons serves as a mother figure?
(Select all that apply.)
Step mother ..........................................................................................
Adoptive mother ....................................................................................
Grandmother .........................................................................................
Father’s significant other .......................................................................
Play mother ...........................................................................................
Aunt ......................................................................................................
Foster....................................................................................................
Other (specify) ___________________________________________
No one .................................................................................................
N/A (has contact with biological mother) ...............................................
69.
If this child has no contact with his/her biological father, which of the following persons serves as a father figure?
(Select all that apply.)
Step father ............................................................................................
Adoptive father ......................................................................................
Grandfather ...........................................................................................
Mother’s significant other ......................................................................
Play father .............................................................................................
Uncle .....................................................................................................
Other (specify) ___________________________________________
No one .................................................................................................
N/A (has contact with biological father) .................................................
70.
How would you describe this child’s relationship with his/her mother figure?
Not close at all ......................................................................................
Not very close .......................................................................................
Somewhat close ..................................................................................
Quite close ............................................................................................
Extremely close ....................................................................................
Don’t Know ..........................................................................................
N/A (is with biological mother) ..............................................................
71.
How would you describe this child’s relationship with his/her father figure?
Not close at all ......................................................................................
Not very close .......................................................................................
Somewhat close ..................................................................................
Quite close ............................................................................................
Extremely close ....................................................................................
Don’t Know ..........................................................................................
N/A ........................................................................................................
13
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72.
Is this child’s mother figure a substance abuser?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
N/A (is with biological mother) .............................................................
73.
Is this child’s father figure a substance abuser?
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
N/A ........................................................................................................
14
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ALCOHOL AND OTHER DRUG USE/INTERACTION BACKGROUND
Yes
74.
Has this child ever taken prescription medicine for a
purpose other than its intended use, either taken on
his/her own or given by someone else? ................................
75.
Has this child ever used store bought (over-thecounter) medications inappropriately? ..................................
76.
Has this child ever drunk any alcohol (beer, wine,
hard liquor)? .............................................................................
77.
Has this child ever used tobacco products? .........................
78.
Has this child ever used illegal drugs (marijuana,
hallucinogens, amphetamines, cocaine, inhalants)?............
79.
Has this child ever been a part of transporting drugs
in any way? ...............................................................................
80.
Has this child ever participated in being a ‘lookout’
for drug dealers? ............................................................
81.
Has this child ever participated in selling drugs?........
82.
Has this child ever voiced any negative thoughts or
feelings about his/her guardian’s alcohol or drug
use?..................................................................................
83.
Has this child ever lived in an environment where
drugs were manufactured, used, or sold? ....................
84.
Has this child ever administered drugs to anyone? ....
85.
Has this child ever been present during a drug bust?
15
No
Don’t Know
N/A
(child too young)
A1-24
HEALTH BACKGROUND
Yes
86.
Did this child receive any pre-birth health care
through recommended pre-natal visits by the
mother? ....................................................................................
87.
Did this child test positive for any alcohol or drugs at
birth? .........................................................................................
88.
Did this child need special care services or
equipment at birth, such as ICU or detox? ............................
89.
Does this child go to the doctor or get a check-up at
least once a year? ....................................................................
90.
Does this child go to the dentist or get a check-up at
least once a year? ....................................................................
91.
Is this child’s immunization schedule complete and
up-to-date for his/her age? ......................................................
92.
Did this child test HIV positive at birth? ................................
None
93.
How many times has this child received treatment for
any physical/ medical health problems during his/her
lifetime? ...........................................................................
94.
How many times has this child received treatment for
any mental/psychiatric health problems during
his/her lifetime?...............................................................
95.
How many times has this child been to the
Emergency Room due to any physical/medical health
problems during his/her lifetime? .................................
96.
How many times has this child been to the
Emergency Room due to any mental/ psychiatric
health problems during his/her lifetime? ......................
16
No
One
time
Two
times
Don’t Know
Three
times
Four
times
N/A
(child too young)
Five
times
More
than five
times
A1-25
PART 2
DATE:
|__|__| |__|__| |__|__|__|__|
2 0
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
PERSON COMPLETING |_______________|
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
Part 2 is to be completed by a health care professional through interviewing the mother and reviewing the medical records.
Please indicate what this child’s experience has been with the following childhood illnesses/conditions/diseases during his/her lifetime.
Does this child have a history of…
A.
Asthma
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
B.
No
DK
Sickle Cell Anemia
1
D.
DK
Diabetes
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision? ........................
C.
No
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
No
DK
No
DK
Obesity
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
17
A1-26
E.
Hypertension (high blood pressure)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
F.
No
DK
No
DK
No
DK
No
DK
Allergies (insect bites and stings)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
J.
DK
Allergies (medicine)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
I.
No
Allergies (pollen, mold, house dust mites, animal dander and saliva, and industrial chemicals)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
H.
DK
Frequent colds, bronchitis, other upper respiratory infections
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
G.
No
Ear Infections
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
18
A1-27
K.
Communicable Diseases (Measles, Mumps, Rubella, Chicken Pox, Hepatitis)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
L.
No
DK
No
DK
No
DK
No
DK
Toothaches, cavities, gum disease, and other dental problems
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
P.
DK
Fetal Alcohol Spectrum or Fetal Alcohol Effects
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
O.
No
HIV/AIDS and/or other sexually transmitted diseases
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
N.
DK
Leukemia or other childhood cancers
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
M.
No
Blurred vision, near sightedness, farsightedness
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
19
A1-28
Q.
Physical trauma from accidents (car, bicycle, sports)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
R.
No
DK
No
DK
No
DK
No
DK
Anxiety or Depression (problem with nerves or mood)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
V.
DK
Pink Eye (conjunctivitis), Head Lice, or Ringworm
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
U.
No
Skin Diseases (psoriasis, eczema)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
T.
DK
Urinary tract infections
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
S.
No
Attention-deficit/hyperactivity disorder (ADHD)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
20
A1-29
W.
Eating disorder (anorexia, bulimia, feeding problems)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
X.
No
DK
No
DK
No
DK
No
DK
Developmental delay/disorder in age appropriate motor skills
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
BB.
DK
Uncontrolled anger
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
AA.
No
Self-injurious behaviors (head banging, cutting, biting, scratching)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
Z.
DK
Enuresis (bedwetting) or Encopresis (repeated passing of feces in inappropriate places,
whether voluntary or involuntary)
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
Y.
No
Developmental delay/disorder in age appropriate communication
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
21
A1-30
CC.
Developmental delay/disorder in age appropriate cognition
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
DD.
No
DK
No
DK
Extreme reaction to stimulation
Yes ........................................................................................................
No .........................................................................................................
Don’t Know ...........................................................................................
IF YES,
Yes
a. Ever been treated for it? .............................................
b. Currently under medical supervision?.........................
Developed by Karen Allen, Ph.D., Belinda Biscoe, Ph.D., and Linda White Young, M.S.W.
Not to be used without the written permission of Karen Allen, Ph.D.
22
A1-31
Attachment A-1.3
Parenting Relationship Questionnaire
A1-32
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:
PARENTING RELATIONSHIP QUESTIONNAIRE
Preschool
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Form Approved
OMB No. XXXX-XXXX
Expiration Date XX-XX-XXXX
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
CHILD’S ID# |__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE: Intake |__|
3-mos post-Intake |__|
PERSON COMPLETING |_______________|
6-mos post-Intake |__|
GRANT#
Discharge |__| 6-mos post-Discharge |__|
TI |__|__|__|__|__|__|
A1-33
A1-34
A1-35
A1-36
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:
PARENTING RELATIONSHIP QUESTIONNAIRE
Child and Adolescent
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Form Approved
OMB No. XXXX-XXXX
Expiration Date XX-XX-XXXX
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
CHILD’S ID# |__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE: Intake |__|
3-mos post-Intake |__|
PERSON COMPLETING |_______________|
6-mos post-Intake |__|
GRANT#
Discharge |__| 6-mos post-Discharge |__|
TI |__|__|__|__|__|__|
A1-37
A1-38
A1-39
A1-40
Attachment A-1.4
Parenting Stress Index
A1-41
PARENTING STRESS INDEX
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Form Approved
OMB No. XXXX-XXXX
Expiration Date XX-XX-XXXX
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
CHILD’S ID# |__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE: Intake |__|
3-mos post-Intake |__|
PERSON COMPLETING |_______________|
6-mos post-Intake |__|
GRANT#
Discharge |__| 6-mos post-Discharge |__|
TI |__|__|__|__|__|__|
A1-42
A1-43
A1-44
A1-45
A1-46
A1-47
A1-48
A1-49
A1-50
A1-51
Attachment A-1.5
Social Skills Improvement System (SSIS)
A1-52
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:
SOCIAL SKILLS IMPROVEMENT SYSTEM (SSIS)
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Form Approved
OMB No. XXXX-XXXX
Expiration Date XX-XX-XXXX
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
CHILD’S ID# |__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE: Intake |__|
3-mos post-Intake |__|
PERSON COMPLETING |_______________|
6-mos post-Intake |__|
GRANT#
Discharge |__| 6-mos post-Discharge |__|
TI |__|__|__|__|__|__|
A1-53
A1-54
A1-55
A1-56
A1-57
Attachment A-1.6
Trauma Symptom Checklist for Young Children
A1-58
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:
TRAUMA SYMPTOM CHECKLIST FOR YOUNG CHILDREN
Form Approved
OMB No. XXXX-XXXX
Expiration Date XX-XX-XXXX
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
CHILD’S ID# |__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE: Intake |__|
3-mos post-Intake |__|
PERSON COMPLETING |_______________|
6-mos post-Intake |__|
GRANT#
Discharge |__| 6-mos post-Discharge |__|
TI |__|__|__|__|__|__|
A1-59
A1-60
A1-61
A1-62
A1-63
Attachment A-1.7
BASIS-24®
A1-64
FEBRUARY 23, 2010 FORMAT
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:
OMB No. xxxxx-xxxx
Expiration Date: xx-xx-xxxx
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE:
Intake |__|
6-mos post-Intake |__|
PERSON COMPLETING |_______________|
Discharge |__|
6-mos post-Discharge |__|
GRANT# TI |__|__|__|__|__|__|
BASIS-24 (BEHAVIOR AND SYMPTOM IDENTIFICATION SCALE)
Instructions to Respondents: This survey asks about how you are feeling and doing in different areas of life. Please check
the box below your answer that best describes yourself during the PAST WEEK. Please answer every question. If you are
unsure about how to answer please give the best answer you can.
Quite a
No
A Little
Moderate
Bit of
Extreme
Difficulty Difficulty Difficulty Difficulty Difficulty
DURING THE PAST WEEK, how much difficulty did you have:
1.
Managing your day-to-day life ..................................................
2.
Coping with problems in your life? ............................................
3.
Concentrating? .........................................................................
DURING THE PAST WEEK, how much of the time did you:
4.
Get along with people in your family? .......................................
5.
Get along with people outside your family? ..............................
6.
Get along well in social situations? ...........................................
7.
Feel close to another person? ..................................................
8.
Feel like you had someone to turn to if you needed help? .......
9.
Feel confident in yourself? ........................................................
None
of the
Time
A little
of the
Time
Half
of the
Time
Most
of the
Time
All
of the
Time
Public reporting burden for this collection of information is estimated to average 10 minutes per response; including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance
Officer, Room 7-1045, 1 Choke Cherry Road, 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 OMB control number. The control number for this project is 0930-0269.
A1-65
DURING THE PAST WEEK, how much of the time did you:
None
of the
Time
A little
of the
Time
Half
of the
Time
Most
of the
Time
All
of the
Time
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
10. Feel sad or depressed? ............................................................
11. Think about ending your life?....................................................
12. Feel nervous? ...........................................................................
DURING THE PAST WEEK, how often did you:
13. Have thoughts racing through your head? ................................
14. Think you had special powers? ................................................
15. Hear voices or see things? .......................................................
16. Think people were watching you? ............................................
17. Think people were against you? ...............................................
18. Have mood swings? .................................................................
19. Feel short-tempered? ...............................................................
20. Think about hurting yourself? ...................................................
DURING THE PAST WEEK, how often:
21. Did you have an urge to drink alcohol or take street drugs?.....
22. Did anyone talk to you about your drinking or drug use?..........
23. Did you try to hide your drinking or drug use? ..........................
24. Did you have problems from your drinking or drug use? ..........
Not to be used without licensed agreement and user registration: www.basissurvey.org
Questionnaire copyright © 2001 McLean Hospital.
2
A1-66
Attachment A-1.8
Child Abuse Potential Inventory
A1-67
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:
CHILD ABUSE POTENTIAL INVENTORY
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
Form Approved
OMB No. XXXX-XXXX
Expiration Date XX-XX-XXXX
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE:
Intake |__|
6-mos post-Intake |__|
PERSON COMPLETING |_______________|
Discharge |__|
6-mos post-Discharge |__|
GRANT# TI |__|__|__|__|__|__|
A1-68
CAP INVENTORY FORM VI
Joel S. Milner. Ph.D.
Copyright. 1977. 1982. 1984; Revised Edition 1986
Printed in .the United 'States of America
Name:
Age:
Gender: Male
_
Date:
_
Marital Status: Sin_ Mar_ Sep_ Div_ Wid_
Female
ID#:
Race: Black __ White__ Latino__ Am. Indian __
Number of children in home
Asian Am. _ _ Other (specify)
Highest grade completed
_
_
_
_
INSTRUCTIONS: The following questionnaire includes a series of statements which
may be applied to yourself. Read each of the statements and determine if you AGREE or
DISAGREE with the statement. If you agree with a statement, circle A for agree. If you
disagree with a statement, circle DA for disagree. Be honest when giving your answers.
Remember to read each statement; it is important not to skip any statement.
.000
I never feel sorry for others
I enjoy having pets
I have always been strong and healthy
I like most people
I am a confused person
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
6.
7.
8.
9.
10.
I do not trust most people
People expect too much from me
Children should never be bad
I am often mixed up
Spanking that only bruises a child is okay
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
11.
12.
13.
14.
15.
I always try to check on my child when it's crying
I sometimes act without thinking
You cannot depend on others
I am a happy person
I like to do things with my family
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
16.
17.
18.
19.
20.
Teenage girls need to be protected
I am often angry inside
Sometimes I feel all alone in the world
Everythinq in a home should always be in its place
I sometimes worry that I cannot meet the needs of a child
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
21.
22.
23.
24.
25.
Knives are dangerous for children
I often feel rejected
I am often lonely inside
Little boys should never learn sissy games
I often feel very frustrated
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
1.
2.
3.
4.
5.
.000
All rights reserved. No part of this booklet may be reproduced by any process. electronic or mechanical. including photocopying. audio and/or visual recordrnq. duphcation In an
informational siorage and retrieval system. without the wntten permission of lhe copvnqht owner
-
_.
•
-
-----
A1-69
oeoo
Children should never disobey
,
I love all children
Sometimes I fear that I will lose control of myself
I sometimes wish that my father would have loved me more
I have a child who is clumsy
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
I know what is the right and wrong way to act
My telephone number is unlisted
The birth of a child will usually cause problems in a marriage
I am always a good person
I never worry about my health
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
I sometimes worry that I will not have enough to eat
I have never wanted to hurt someone else
I am an unlucky person
I am usually a quiet person
Children are pests
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
43.
44.
45.
Things have usually gone against me in life
Picking up a baby whenever he cries spoils him
I sometimes am very quiet
I sometimes lose my temper
I have a child who is bad
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
46.
47.
48.
49.
50.
I sometimes think of myself first
I sometimes feel worthless
My parents did not really care about me
I am sometimes very sad
Children are really little adults
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
51.
I have a child who breaks things
I often feel worried
It is okay to let a child stay in dirty diapers for a while
A child should never talk back
Sometimes my behavior is childish
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
I am often easily upset
Sometimes I have bad thoughts
Everyone must think of himself first
A crying child will never be happy
I have never hated another person
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
Children should not learn how to swim
I always do what is right
I am often worried inside
I have a child\ who is sick a lot
Sometimes I do not like the way I act
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
I sometimes fail to keep all of my promises
People have caused me a lot of pain
Children should stay clean
I have a child who gets into trouble a lot
I never get mad at others
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
oeoo
A1-70
00.0
71.
72.
73.
74.
75.
I always get along with others
'
I often think about what I have to do
I find it hard to relax
These days a person doesn't really know on whom one can count
My life is happy
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
. DA
DA
76.
77.
78.
79.
80.
I have a physical handicap
Children should have play clothes and good clothes
Other people do not understand how I feel
A five year old who wets his bed is bad
Children should be quiet and listen
"
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
81.
82.
83.
84.
85.
I have several close friends in my neighborhood
The school is primarily responsible for educating the child
My family fights a lot
I have headaches
As a child I was abused
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
86.
87.
88.
89.
90.
Spanking is the best punishment
I do not like to be touched by others
People who ask for help are weak
Children should be washed before bed
I do not laugh very much
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
91.
92.
93.
94.
95.
I have several close friends
People should take care of their own needs
I have fears no one knows about
My family has problems getting along
Life often seems useless to me
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
A child should be potty trained by the time he's one year old
A child in a mud puddle is a happy sight
People do not understand me
I often feel worthless
Other people have made my life unhappy
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
96.
97.
98.
99.
100.
101. I am always a kind person
102. Sometimes I do not know why I act as I do
103. I have many personal problems
104. I have a child who often hurts himself
105. I often feel very upset
106.
107.
108.
109.
110.
People sometimes take advantage of me
My life is good
A home should be spotless
I am easily upset by my problems
I never listen to gossip
111. My parents did not understand me
112. Many things in life make me angry
113. My child has special problems
114. I do not like most children
115. Children should be seen and not heard
"
.
.
00.0
A1-71
000.
116.
117.
118.
119.
120.
Most children are alike
It is important for children to read
I am often depressed
Children should occasionally be thoughtful of their parents
I am often upset
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
121.
122.
123.
124.
125.
People don't get along with me
A good child keeps his toys and clothes neat and orderly
Children should always make their parents happy
It is natural for a child to sometimes talk back
I am never unfair to others
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
126.
127.
128.
129.
130.
Occasionally, I enjoy not having to take care of my child
Children should always be neat
I have a child who is slow
A parent must use punishment if he wants to control a child's behavior
Children should never cause trouble
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
131.
132.
133.
134.
135.
I usually punish my child when it is crying
A child needs very strict rules
Children should never go against their parents' orders
I often feel better than others
Children sometimes get on my nerves
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
136.
137.
138.
139.
140.
As a child I was often afraid
Children should always be quiet and polite
I am often upset and do not know why
My daily work upsets me
I sometimes fear that my children will not love me
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
141.
142.
143.
144.
145.
I have a good sex life
I have read articles and books on child rearing
I often feel very alone
People should not show anger
I often feel alone
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
146.
147.
148.
149.
150.
I sometimes say bad words
Right now, I am deeply in love
My family has many problems
I never do anything that is bad for my health
I am always happy with what I have
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
151.
152.
153.
154.
155.
Other people have made my life hard
I laugh some almost every day
I sometimes worry that my needs will not be met
afraid
I often feel
\
1sometimes act silly
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
156.
157.
158.
159.
160.
A person should keep his business to himself
I never raise my voice in anger
As a child I was knocked around by my parents
I sometimes think of myself before others
I always tell the truth
.
.
.
.
.
A
A
A
A
A
DA
DA
DA
DA
DA
.
~
000.
A1-72
Attachment A-1.9
Family Support Scale
A1-73
FAMILY SUPPORT SCALE
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
Form Approved
OMB No. XXXX-XXXX
Expiration Date XX-XX-XXXX
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE:
Intake |__|
6-mos post-Intake |__|
PERSON COMPLETING |_______________|
Discharge |__|
6-mos post-Discharge |__|
GRANT# TI |__|__|__|__|__|__|
A1-74
Family Support Scale
Carl J Dunst, Carol M Trivette, and Vicki Jenkins
Name
_
Date
_
Listedbelowarepeopleand groupsthat oftentimesarehelpful to membersof a familyraisinga young child.This questionnaire
asks you to indicate how helpful each source is to your family. Please circle the response that best describes how helpful
the people and groups have been to your family during the past 3 to 6 months. If a source of help has not been available to
your family during this period oftirne, circle the NA (Not Available) response.
How helpful has each ofthe following
been to you in terms of raising your
child(ren)?
Not
Available
Not at All Sometimes Generally
Helpful
Helpful
Helpful
Very
Helpful
Extremely
Helpful
1. My parents
NA
2
3
4
5
2. My spouse or partner's parents
NA
2
3
4
5
3. My relativeslkin
NA
2
3
4
5
4. My spouse or partner's relativeslkin
NA
2
3
4
5
5. My spouse or partner
NA
2
3
4
5
6. My friends
NA
2
3
4
5
7. My spouse or partner's friends
NA
2
3
4
5
8. My older child(ren)
NA
2
3
4
5
9. Neighbors
NA
2
3
4
5
10. Other parents
NA
2
3
4
5
11. Co-workers
NA
2
3
4
5
12. Parent group members
NA
2
3
4
5
13. Social groups/clubs
NA
2
3
4
5
14. Church members/minister
NA
2
3
4
5
15. My family or child's physician
NA
2
3
4
5
16. Early childhood intervention
program
NA
2
3
4
5
17. Schoolldaycare center
NA
2
3
4
5
18. Professional helpers (social workers,
therapists, teachers, etc.)
NA
2
3
4
5
19. Professional agencies (public health,
social services, mental health, etc.)
NA
2
3
4
5
20.
NA
2
3
4
5
21.
NA
2
3
4
5
Winterberry Assessment Scales & Instruments
3
A1-75
Attachment A-1.10
Ferrans and Powers Quality of Life Index
A1-76
FEBRUARY 23, 2010 FORMAT
Readmit |__|
2 Phases |__|
Initial |__|__|
DATE:
Form Approved
OMB No. xxxx-xxxx
Expiration Date xx-xx-xxxx
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
FAMILY ID# 8 |__|__|
2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
RESPONDENT:
Mother |__|
Mother’s partner |__|
Child’s father |__|
Other |__| Specify: ________________
IF RESPONDENT IS NOT THE MOTHER, What are the Child IDs of the children he or she has a relationship with?
|__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__|
IF RESPONDENT IS THE BIOLOGICAL FATHER, What are the Child IDs of his biological children?
|__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__| , |__|__|
EVALUATION PHASE:
Intake |__|
6-mos post-Intake |__|
(MOTHER ONLY)
PERSON COMPLETING |_______________|
Discharge |__|
GRANT#
6-mos post-Discharge |__|
(MOTHER ONLY)
TI |__|__|__|__|__|__|
FERRANS AND POWERS QUALITY OF LIFE INDEX©
GENERIC VERSION – III
PART 1. For each of the following, please choose the answer that best describes how satisfied you are with that area of your life.
Please mark your answer by checking the box. There are no right or wrong answers.
Very
dissatisfied
How satisfied are you with:
1.
Your health? ......................................................
2.
Your health care? ..............................................
3.
The amount of pain that you have? ...................
4.
The amount of energy you have for everyday
activities? ..........................................................
5.
Your ability to take care of yourself without
help? .................................................................
6.
The amount of control you have over your life?
7.
Your chances of living as long as you would
like? ...................................................................
8.
Your family’s health? .........................................
9.
Your children? ...................................................
Moderately
dissatisfied
Slightly
dissatisfied
Slightly
satisfied
Moderately
satisfied
Very
satisfied
10. Your family’s happiness? ..................................
11. Your sex life? ....................................................
12. Your spouse, lover, or partner? .........................
13. Your friends? .....................................................
Public reporting burden for this collection of information is estimated to average 15 minutes per response; including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1044, 1
Choke Cherry Road, 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 OMB control number. The control number for this project is 0930-0269.
© Copyright 1984 & 1998 Carol Estwing Ferrans and Marjorie J. Powers
A1-77
Very
dissatisfied
How satisfied are you with:
Moderately
dissatisfied
Slightly
dissatisfied
Slightly
satisfied
Moderately
satisfied
Very
satisfied
14. The emotional support you get from your
family? ...............................................................
15. The emotional support you get from people
other than your family? ......................................
16. Your ability to take care of family
responsibilities?.................................................
17. How useful you are to others?...........................
18. The amount of worries in your life? ...................
19. Your neighborhood? ..........................................
20. Your home, apartment, or place where you
live? ...................................................................
21. Your job (if employed)? .....................................
22. Not having a job (if unemployed, retired, or
disabled)?..........................................................
23. Your education? ................................................
24. How well you can take care of your financial
needs? ..............................................................
25. The things you do for fun?.................................
26. Your chances for a happy future? .....................
27. Your peace of mind? .........................................
28. Your faith in God? .............................................
29. Your achievement of personal goals? ...............
30. Your happiness in general?...............................
31. Your life in general? ..........................................
32. Your personal appearance? ..............................
33. Yourself in general? ..........................................
PART 2. For each of the following, please choose the answer that best describes how important that area of your life is to you. Please
mark your answer by checking the box. There are no right or wrong answers.
How important to you is:
1.
Your health? ...................................................
2.
Your health care? ...........................................
3.
Having no pain? .............................................
4.
Having enough energy for everyday
activities? .......................................................
5.
Taking care of yourself without help? .............
6.
Having control over your life? .........................
Very
unimportant
Moderately
unimportant
2
Slightly
unimportant
Slightly
important
Moderately
important
Very
important
A1-78
How important to you is:
7.
Living as long as you would like? ...................
8.
Your family’s health? ......................................
9.
Your children? ................................................
Very
unimportant
Moderately
unimportant
10. Your family’s happiness? ...............................
11. Your sex life? .................................................
12. Your spouse, lover, or partner? ......................
13. Your friends? ..................................................
14. The emotional support you get from your
family? ............................................................
15. The emotional support you get from people
other than your family? ...................................
16. Taking care of family responsibilities? ............
17. Being useful to others?...................................
18. Having no worries?.........................................
19. Your neighborhood? .......................................
20. Your home, apartment, or place where you
live? ................................................................
21. Your job (if employed)? ..................................
22. Having a job (if unemployed, retired, or
disabled)?.......................................................
23. Your education? .............................................
24. Being able to take care of your financial
needs? ...........................................................
25. Doing things for fun? ......................................
26. Having a happy future? ..................................
27. Peace of mind? ..............................................
28. Your faith in God? ..........................................
29. Achieving your personal goals? .....................
30. Your happiness in general?............................
31. Being satisfied with life? .................................
32. Your personal appearance? ...........................
33. Are you to yourself? .......................................
3
Slightly
unimportant
Slightly
important
Moderately
important
Very
important
A1-79
Attachment A-1.11
Items Administered to Women
A1-80
READMIT |__|
INITIALS |__|__|
DATE:
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
2 0
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE:
Intake ||
PERSON COMPLETING |___________________| GRANT# TI |__|__|__|__|__|__|
INTAKE: ITEMS ADMINISTERED TO WOMEN
This tool is to be administered to women by project staff at intake.
1.
How many of your children, if any, are living with you in this residential treatment program?
|__|__|
2.
None |__|
During the past 30 days, how many days have you smoked cigarettes?
0-30 days|__|__|
3.
Refused |__|
Refused |__|
Refused |__|
Don’t know |__|
Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone?
Yes |__|
6.
Don’t know |__|
During the past 30 days, how many days have you used chewing tobacco, snuff, or dip?
0-30 days|__|__|
5.
Don’t know |__|
During the past 30 days, how many days have you smoked cigars, cigarillos, or pipes?
0-30 days|__|__|
4.
Don’t know |__|
No |__|
Refused |__|
Don’t know |__|
Within the last year, has anyone forced you to have sexual activities that made you feel uncomfortable?
Yes |__|
No |__|
Refused |__|
Don’t know |__|
A1-81
READMIT |__|
INITIALS |__|__|
DATE:
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
2 0
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE:
6-mos post-Intake || PERSON COMPLETING |_______________| GRANT# TI |__|__|__|__|__|__|
6 MONTHS POST-INTAKE: ITEMS ADMINISTERED TO WOMEN
This tool is to be administered to women by project staff at six months post-intake.
1.
IF STILL IN TREATMENT, How many of your children, if any, are living with you in this residential treatment program?
|__|__|
2.
Not still in treatment |__|
Refused |__|
Don’t know |__|
During the past 30 days, how many days have you smoked cigars, cigarillos, or pipes?
0-30 days|__|__|
4.
Don’t know |__|
During the past 30 days, how many days have you smoked cigarettes?
0-30 days|__|__|
3.
None |__|
Refused |__|
Don’t know |__|
During the past 30 days, how many days have you used chewing tobacco, snuff, or dip?
0-30 days|__|__|
Refused |__|
Don’t know |__|
A1-82
READMIT |__|
INITIALS |__|__|
DATE:
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
2 0
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
2 0
WOMAN’S DISCHARGE DATE: |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE:Discharge |__| PERSON COMPLETING
|_______________| GRANT# TI |__|__|__|__|__|__|
DISCHARGE: ITEMS ADMINISTERED TO WOMEN
This tool is to be administered to women by project staff at discharge.
1.
Just prior to discharge, how many of your children, if any, lived with you in this residential treatment program?
|__|__|
2.
Refused |__|
Don’t know |__|
During the past 30 days, how many days have you smoked cigars, cigarillos, or pipes?
0-30 days|__|__|
4.
Don’t know |__|
During the past 30 days, how many days have you smoked cigarettes?
0-30 days|__|__|
3.
None |__|
Refused |__|
Don’t know |__|
During the past 30 days, how many days have you used chewing tobacco, snuff, or dip?
0-30 days|__|__|
Refused |__|
Don’t know |__|
A1-83
READMIT |__|
INITIALS |__|__|
DATE:
2 0
|__|__| |__|__| |__|__|__|__|
START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|
END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|
2 0
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
2 0
WOMAN’S DISCHARGE DATE: |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE: 6 months post-Discharge |__| PERSON COMPLETING |_______________| GRANT# TI|__|__|__|__|__|__|
6 MONTHS POST-DISCHARGE: ITEMS ADMINISTERED TO WOMEN
This tool is to be administered to women by project staff at six months post-discharge.
1.
During the past 30 days, how many days have you smoked cigarettes?
0-30 days|__|__|
2.
Refused |__|
During the past 30 days, how many days have you smoked cigars, cigarillos, or pipes?
0-30 days|__|__|
3.
Refused |__|
Don’t know |__|
No |__|
Refused |__|
Don’t know |__|
Since you left treatment, has anyone forced you to have sexual activities that made you feel uncomfortable?
Yes |__|
6.
Refused |__|
Since you left treatment, have you been hit, slapped, kicked or otherwise physically hurt by someone?
Yes |__|
5.
Don’t know |__|
During the past 30 days, how many days have you used chewing tobacco, snuff, or dip?
0-30 days|__|__|
4.
Don’t know |__|
No |__|
Refused |__|
Don’t know |__|
Since leaving treatment, have you received support in your recovery from any of the following? Select all that apply.
Additional treatment (inpatient or outpatient) |__|
Self-help groups |__|
Community or faith-based programs |__|
Other (specify)__________________ |__|
Family/friend support |__|
I have not received any support |__|
Refused |__|
A1-84
Attachment A-1.12
Site Visit Protocol – Client Focus Groups
A1-85
TI # __________
Client Focus Group Protocol
(2/15/10)
[Interviewer: Start tape recorder and explain the purpose of the focus group session by saying:]
Introduction and Overview (5 minutes)
Hello. My name is ________ and this is ___________ we are from Westat, a research
consulting company. We’d like to welcome you and thank you for joining us today.
I’d like to take a few minutes to review the purpose of this focus group meeting and why we are
using an audiotape recorder. We are conducting a cross-site evaluation of PPW programs on
behalf of the Substance Abuse and Mental Health Services Administration (SAMHSA), Center
for Substance Abuse Treatment (CSAT). The purpose of this study is to evaluate the
effectiveness of PPW programs that received Federal funds and obtain information about how
they can be improved. As part of this study, Westat is conducting site visits to PPW programs
and focus groups with PPW clients. You are being asked to participate in this focus group
because of your participation in this PPW program.
We want to speak with you today because we are interested in learning about your experience in
this residential treatment program. This focus group will last about one to one and a half hours.
We do not expect you to answer our questions in any particular way, there are no right or wrong
answers; the important thing is for you to share your experience and opinions. You are the experts
and we would like to learn from you. The information you share with us may be used to help
other women who participate in this program after you, and/or women in similar programs across
the country.
To ensure that we obtain accurate information, we will be audiotape recording this focus group
as well as taking detailed notes. All information provided during this focus group will be kept
private. This tape recording will be kept in a locked file cabinet to ensure your privacy, and we
will only use your first name during the focus group.
To ensure your privacy, we will not link an individual’s name with a specific response when
reporting our results and we will not include any names in the transcript that is made of this
focus group. When reporting our results, your responses will be combined with information
provided by other clients (including clients in other PPW programs funded by CSAT) and
reported in summary form.
Please note that there are limits to the privacy of the information reported in this focus group,
and if we learn of threats to your personal safety (e.g., suicidal thoughts) or the safety of others
(e.g., current child abuse and/or neglect, homicidal thoughts) we will report this information to
PPW program staff.
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You may refuse to participate in this focus group and you may stop participating at any time.
You also do not have to answer any questions that you do not want to answer.
Does anyone have any questions?
To ensure that each of you understands all that is involved with this focus group we have consent
forms for each of you to read and sign. Please take a moment to read the consent form and sign
when you are ready.
Thank you.
[Interviewer: Explain the process and rules of the focus group session by saying:]
Focus Group Process (5 minutes)
This discussion will take about one and one-half hours. To help us learn as much as possible
from each other, we would like to share some group rules:
Group Rules
You are the experts! We are here to learn from you.
Everyone’s ideas count. Please respect everyone’s right to their opinions.
There are no right or wrong answers. Everything you have to say is valuable. If something is
important to you, it’s important to us.
Please speak one person at a time; otherwise, it will be hard for us to understand what each of
you is saying.
The discussion today is private and should remain in this room.
Neither I nor any members of my team will reveal any personal information to other people
and we ask that you also do not share the details of this discussion with others.
Please turn off electronic devices (i.e., cell phones)
Does anyone have any questions?
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Focus Group Questions (60 minutes)
[Interviewer: The tone of the focus group should be conversational and respectful of the
expertise of the participants. Be prepared to explore answers to questions using prompts, such as
“Can you tell me more about that?”, “What makes you say that?”, and “Can you explain that to
me please?” Additionally, be prepared to explore unanticipated topics that may be raised by
participants during the course of the discussion.]
1.
How long have each of you been living in this program?
a. If applicable to the program’s treatment model, what phase of the program are
each of you in?
2. How many of you are pregnant? How many of you are post-partum?
3. Do you feel that the living conditions in this program:
a. Are homelike, welcoming, and culturally appropriate?
b. Facility is safe and secure (entry to the program is protected, security procedures
in place)?
c. Safe neighborhood in terms of crime and drug use?
d. Program common areas are for women only?
e. Smoking areas are safe and secure?
4. Do you feel that this program is responsive to specific needs of pregnant and post-partum
women, and women with children?
a. Probe for examples.
5. Do you feel that this program is responsive to specific needs of women with trauma
experiences (e.g., history of physical and/or sexual abuse)?
a. Probe for examples.
6. Do you feel that this program is responsive to/meeting your own specific needs?
a. Probe for examples.
Women’s Services
7. Have there been any specific services or activities that you have received/participated in
here that have helped you to:
a. Stay clean and sober?
b. Improve the physical health of you and/or your children?
c. Improve your relationship with your children (including those who live with you
in this program and those that do not currently live with you)?
d. Build better relationships with other family members (including the father(s) of
your children, partner/spouse, parent, sibling, etc.)?
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e. Develop better strategies to reduce your exposure to/experience with
violence/abuse?
f. Develop skills to find a job once you leave this program?
g. Develop skills to locate permanent housing once you leave this program?
8. On average how many of the following services have you received/participated in:
a. Counseling sessions per week?
i. Probe for examples (individual, couples/family).
ii. Onsite or off-site?
iii. Do you have the same counselor as when you started in the program or has
your counselor changed (e.g., consistency of staff)?
1. If no, do you know why you have a different counselor?
iv. How available is your counselor if you need to talk to her (e.g., by
appointment only, as needed during the day shift, 24 hours a day, some
other schedule)?
b. Educational group sessions (e.g., parenting skills, GED, health issues) per week?
i. Probe for examples.
ii. Onsite or off-site?
c. Medical services (physical exam, laboratory testing, GYN exam, treatment for an
existing or new medical condition) since entering into this program?
i. Probe for examples.
ii. Onsite or off-site?
9. For any off-site services, has the program assisted you in accessing off-site services and
activities? (If yes, in what ways?)
a. What has been your experience in accessing off-site services?
Now I’d like to ask you some questions about the services offered to your children and other
family members.
Children’s and Family Services
10. How many of you have children living with you in this program?
a. How old are these children?
b. How much time do you spend with your children in this program?
c. What types of services have they received: Probe for:
i. Medical (onsite or offsite)
ii. Mental health (onsite or off-site)
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11. Has this program provided any services to your children who do not live with you here,
and/or your family members?
a. What types of services have they received from this program? Probe for:
i. Education/Information
ii. Referrals for services
iii. Treatment services (e.g., individual mental health, medical services for
themselves, couples/family treatment)
12. How many of you have family members that you would like to participate in this
program that are currently not involved?
a. Why have they not been able to participate (Probe: any programmatic barriers to
inclusion of these family members)?
Program Strengths and Weaknesses
13. What do you see as the strengths of this program and how has it supported your own
recovery?
14. What do you see as the weaknesses of this program?
Probe: Any problems you have encountered and how have they been resolved?
15. What services are not currently provided in this program that you think would help your
own recovery, or your children and/or family (i.e., any recommendations for how the
program can be improved)?
16. Would you recommend a program like this to other women? Why or Why not?
Thank you very much for taking the time to participate in this focus group with us today !
| File Type | application/pdf |
| File Title | Attachment A-1 - Instruments for Mothers |
| Author | Victoria Castleman |
| File Modified | 2010-09-01 |
| File Created | 2010-09-01 |