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pdfD-1
ATTACHMENT D:
INSTRUMENTS FOR PROJECT STAFF
D-1
Children’s Discharge Tool
D-2
Women’s Discharge Tool
D-3
Staff Completed Women’s Items
D-4
Staff Completed Child Items
D-2
Attachment D-1
Children’s Discharge Tool
D-3
FEBRUARY 23, 2010 FORMAT
Readmit |__|
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 |__|__| |__|__| |__|__|__|__|
CHILD’S DISCHARGE DATE:
EVALUATION PHASE:
2 0
|__|__| |__|__| |__|__|__|__|
Discharge |__|
PERSON COMPLETING
|_______________| GRANT#
TI |__|__|__|__|__|__|
CHILDREN’S DISCHARGE TOOL
At the time a child is discharged from treatment, this is to be completed by project staff based on review of each child’s treatment
records.
1.
Length of stay
Less than 30 days ..........
30 days ...........................
31 – 45 days ...................
46 – 60 days ...................
61 – 90 days ...................
91 – 120 days .................
121 – 180 days ...............
181 – 270 days ...............
More than 270 days ........
2.
Treatment completion
Yes
No
3.
Goals of Treatment Plan
None achieved ............
¼ achieved .................
½ achieved .................
¾ achieved .................
All achieved .................
Public reporting burden for this collection of information is estimated to average 35 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.
D-4
4. Has this child resided in this residential treatment facility with the mother?
Yes...............................................................................................
No ................................................................................................
4a. IF NOT, On average, how often has this child visited the mother while she was staying in this residential
treatment facility?
More than once a week................................................................
Weekly .........................................................................................
2-3 times per month .....................................................................
Monthly ........................................................................................
Less than monthly ........................................................................
Never ...........................................................................................
N/A – child .................................................................................
5.
When the child leaves treatment, who will he/she be living with? (Select all that apply.)
Mother..........................................................................................
Father ..........................................................................................
Grandparent.................................................................................
Other relative ..............................................................................
Friend...........................................................................................
Foster care ...................................................................................
Institution .....................................................................................
Other (specify) _____________________________________ ...
6.
Why is this child being discharged at this time? (Select all that apply.)
Mother being discharged from residential facility .........................
Mother being discharged from treatment altogether .....................
Child’s treatment complete ...........................................................
Child’s administrative discharge ...................................................
Child going to live elsewhere .......................................................
Mother’s request ..........................................................................
Mother’s parental rights terminated ..............................................
Other (specify) ______________________________________
2
D-5
SERVICES RECEIVED
COLUMN ‘A’ RESPONSES
1 = Yes
0 = No
-1 = N/A
-8 = Don’t know
0
1
2
3
4
5
6
7
-1
NUMBER OF SESSIONS
COLUMN ‘B’ RESPONSES
= No sessions
= Once
= Every few months
= Monthly
= 2-3 x/month
= Weekly
= 2-6 x/week
= Daily
= N/A
1
2
3
4
5
6
7
-1
=
=
=
=
=
=
=
=
WHERE AND BY WHOM
COLUMN ‘C’ RESPONSES
On-site by PPW project staff
On-site by another agency
Off-site by PPW project staff
Off-site by another agency
On-site by PPW parent organization staff
Off-site by PPW parent organization staff
Both on-site and off-site
N/A
Choose the response category that most closely describes the services received by this child. Record the corresponding
value in the box for each column: A – Services Received, B – Number of Sessions, and C – Where and by Whom.
If a child is given a N/A for receiving a service in Column A, then it is anticipated that the child will also receive N/A or None
in Columns B-C.
SERVICE/TREATMENT ACTIVITY
A
Services
Received
B
Sessions
C
Where and
by Whom
1.
Developmental Assessment (based on standardized
form/process) ........................................................................................
|___|
|___|
|___|
2.
Physical Exam by Healthcare Providers (including height,
weight, vital signs, BMI, body systems: respiratory, cardiac,
gastrointestinal, genitor-urinary, skin, neurological) ..............................
|___|
|___|
|___|
3.
Laboratory Testing (urinalysis, complete blood count,
electrolytes, HIV/AIDS & STDs) ............................................................
|___|
|___|
|___|
4.
Immunization Updates ..........................................................................
|___|
|___|
|___|
5.
Vision Screening (used standard eye charts) .......................................
|___|
|___|
|___|
6.
Speech and Hearing Assessment.........................................................
|___|
|___|
|___|
7.
Dental Assessment (done by dentist) ...................................................
|___|
|___|
|___|
8.
Nutritional Assessment (done by registered dietitian) ..........................
|___|
|___|
|___|
9
Medical Diagnosing and Follow-up Treatment......................................
|___|
|___|
|___|
10.
Mental Status Exam for Children ..........................................................
|___|
|___|
|___|
11.
Recreational Activity (field trips, movies, team sports, cultural
experiences, picnics) ............................................................................
|___|
|___|
|___|
12.
Spiritual Activity (meditational activities, attendance at services,
watching video tapes, listening to tapes, etc.) ......................................
|___|
|___|
|___|
13.
Individual Nurturing (0 to 5 yrs) (this includes being held,
rocked, infant massage/stimulation, reading to them, singing
to/with them, listening to them and dialoguing with them).....................
|___|
|___|
|___|
3
D-6
SERVICE/TREATMENT ACTIVITY (Continued)
A
Services
Received
B
Sessions
C
Where and
by Whom
14.
Individual Counseling Related to Effects of Substance Abuse
(5 to 17 yrs) ..........................................................................................
|___|
|___|
|___|
15.
Substance Abuse Prevention Education/Classes .................................
|___|
|___|
|___|
16.
Play Therapy ........................................................................................
|___|
|___|
|___|
17.
Art Therapy ...........................................................................................
|___|
|___|
|___|
18.
Group Counseling for Children of Substance Abusers .........................
|___|
|___|
|___|
19.
Attend AlaTot ........................................................................................
|___|
|___|
|___|
20.
Attend AlaTeen .....................................................................................
|___|
|___|
|___|
21.
Mother-Child Parenting/Bonding Classes .............................................
|___|
|___|
|___|
22.
Father-Child Parenting/Bonding Classes ..............................................
|___|
|___|
|___|
23.
Mother/Father/Child Counseling/Classes .............................................
|___|
|___|
|___|
24.
Trauma-related Counseling ..................................................................
|___|
|___|
|___|
25.
Individual Psychiatric Therapy (based on psychiatric diagnosis) ..........
|___|
|___|
|___|
26.
Group Psychiatric Therapy (based on psychiatric diagnosis) ...............
|___|
|___|
|___|
27.
Special/Remedial Education (for learning disabled) .............................
|___|
|___|
|___|
28.
Evidence of Aftercare Plan ...................................................................
|___|
|___|
|___|
29.
Established Socio-economic Support at State and Federal
Level (if eligible) ....................................................................................
|___|
|___|
|___|
30.
Physical Therapy ..................................................................................
|___|
|___|
|___|
31.
Speech Therapy ...................................................................................
|___|
|___|
|___|
32.
Occupational Therapy...........................................................................
|___|
|___|
|___|
Not to be used without the written permission of Karen Allen, Ph.D.
4
D-7
Attachment D-2
Women’s Discharge Tool
D-8
FEBRUARY 23, 2010 FORMAT
Readmit |__|
Initial |__|__|
DATE:
Form Approved
OMB No. xxxx-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 |__|__| |__|__| |__|__|__|__|
WOMAN’S DISCHARGE DATE:
2 0
|__|__| |__|__| |__|__|__|__|
DISCHARGE |__|
EVALUATION PHASE:
PERSON COMPLETING |_______________|
GRANT#
TI |__|__|__|__|__|__|
WOMEN’S DISCHARGE TOOL
At the time a woman is discharged from treatment, this is to be completed by project staff based on review of each woman’s treatment
records.
1.
Length of stay
2.
Less than 30 days ...............
30 days ...............................
31 – 45 days .......................
46 – 60 days .......................
61 – 90 days .......................
91 – 120 days .....................
121 – 180 days ...................
181 – 270 days ...................
More than 270 days ............
4.
Treatment completion
Yes ................................
No .................................
3.
Goals of Treatment Plan
None achieved ................
¼ achieved .....................
½ achieved .....................
¾ achieved .....................
All achieved.....................
At intake, was this woman pregnant, postpartum (less than 12 months since her last delivery), or both?
Pregnant .......................................................................................
Postpartum ...................................................................................
Both Pregnant and Postpartum ....................................................
Neither Pregnant nor Postpartum .................................................
Public reporting burden for this collection of information is estimated to average 35 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
D-9
SERVICES RECEIVED
COLUMN ‘A’ RESPONSES
1
0
-1
-8
=
=
=
=
NUMBER OF SESSIONS
COLUMN ‘B’ RESPONSES
WHERE AND BY WHOM
COLUMN ‘C’ RESPONSE
Yes
No
N/A
Don’t know
0 = No sessions
1 = On-site by PPW project staff
1 = Once
2 = On-site by another agency
2 = Every few months
3 = Off-site by PPW project staff
3 = Monthly
4 = Off-site by another agency
4 = 2-3 x/month
5 = On-site by PPW parent organization staff
5 = Weekly
6 = Off-site by PPW parent organization staff
6 = 2-6 x/week
7 = Both on-site and off-site
7 = Daily
-1 = N/A
-1 = N/A
In the following section, choose the response category that most closely describes the services received by this woman. Record the
corresponding value in the box for each column: A – Services Received, B – Number of Sessions, and
C – Where and by Whom.
If a woman is given a N/A for receiving a service in Column A, then it is anticipated that the woman will also receive N/A or NONE in
Columns B-C.
SERVICE/TREATMENT ACTIVITY
A
Services
Received
B
Sessions
C
Where and
by Whom
1.
Outreach, Screening, and Assessment ........................................................
|___|
|___|
|___|
2.
Detoxification ................................................................................................
|___|
|___|
|___|
3.
Case Management Services ........................................................................
|___|
|___|
|___|
4.
Substance Abuse Education and Treatment ................................................
|___|
|___|
|___|
5.
Physical Exam by Healthcare Providers (including height, weight,
vital signs, BMI, body systems: respiratory, cardiac,
gastrointestinal, genitor-urinary, skin, neurological) .....................................
|___|
|___|
|___|
6.
Laboratory Testing (urinalysis, complete blood count, electrolytes,
HIV/AIDS and STDs) ....................................................................................
|___|
|___|
|___|
7.
Education, Screening, Counseling, and Treatment of Hepatitis,
HIV/AIDS, other STDs ..................................................................................
|___|
|___|
|___|
8
Vision Screening (used standard eye charts) ...............................................
|___|
|___|
|___|
9.
Speech and Hearing Assessment ................................................................
|___|
|___|
|___|
10.
Dental Assessment (done by dentist) ...........................................................
|___|
|___|
|___|
11.
Nutritional Assessment (done by registered dietitian) ..................................
|___|
|___|
|___|
12.
Medical Diagnosing and Follow-up Treatment .............................................
|___|
|___|
|___|
13.
Prenatal Health Care ....................................................................................
|___|
|___|
|___|
14.
Postpartum Health Care ...............................................................................
|___|
|___|
|___|
15.
Mental Health Assessment ..........................................................................
|___|
|___|
|___|
D-10
SERVICE/TREATMENT ACTIVITY (continued)
16.
Mental Health Treatment ..............................................................................
17.
Trauma-informed services, including assessment and interventions for:
A
Services
Received
B
Sessions
C
Where and
by Whom
|___|
|___|
|___|
a.
Emotional abuse....................................................................................
|___|
|___|
|___|
b.
Sexual abuse ........................................................................................
|___|
|___|
|___|
c.
Physical abuse ......................................................................................
|___|
|___|
|___|
18.
Recreational Activity (field trips, movies, team sports, cultural
experiences, picnics) ....................................................................................
|___|
|___|
|___|
19.
Spiritual Activity (meditational activities, attendance at services,
watching video tapes, listening to tapes, etc.) ..............................................
|___|
|___|
|___|
20.
Employment Readiness, Training .................................................................
|___|
|___|
|___|
21.
Employment Placement................................................................................
|___|
|___|
|___|
22.
Permanent Housing Arrangements ..............................................................
|___|
|___|
|___|
23.
Childcare ......................................................................................................
|___|
|___|
|___|
24.
Transportation ..............................................................................................
|___|
|___|
|___|
25.
Mother-Child Parenting/Bonding Classes .....................................................
|___|
|___|
|___|
26.
Mother/Child Counseling/Classes ................................................................
|___|
|___|
|___|
27.
Individual Psychiatric Therapy (based on psychiatric diagnosis) ..................
|___|
|___|
|___|
28.
Group Psychiatric Therapy (based on psychiatric diagnosis) .......................
|___|
|___|
|___|
29.
Individual Substance Abuse Counseling ......................................................
|___|
|___|
|___|
30.
Group Substance Abuse Counseling............................................................
|___|
|___|
|___|
31.
Family Therapy .............................................................................................
|___|
|___|
|___|
32.
Educational Services (for GED and other educational needs)......................
|___|
|___|
|___|
33.
Discharge Planning (including community reintegration) ..............................
|___|
|___|
|___|
34.
Planned or Arranged Post Residential Treatment Continuing Care .............
|___|
|___|
|___|
35.
Established Socio-economic Support at State and Federal Level
(if eligible) .....................................................................................................
|___|
|___|
|___|
Not to be used without the written permission of Karen Allen, Ph.D.
D-11
Attachment D-3
Staff Completed Women’s Items
D-12
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: STAFF COMPLETED WOMEN’S ITEMS
This is to be completed by project staff at intake.
1.
2.
Is this woman pregnant, postpartum (less than 12 months since her last delivery), or both?
Pregnant |__|
Both Pregnant and Postpartum |__|
Postpartum |__|
Neither Pregnant nor Postpartum |__|
If PREGNANT, at what trimester of pregnancy is this woman?
First (week 1 to week 12) |__|
Don’t know |__|
Second (week 13 to week 26) |__|
N/A |__|
Third (week 27 to delivery) |__|
3.
4.
If PREGNANT, has this woman experienced any problems during pregnancy? Select all that apply.
Gestational diabetes |__|
Other (specify) ___________________________ |__|
Preeclampsia or pregnancy induced hypertension |__|
None|__|
Sexually Transmitted Diseases (STDs) |__|
Don’t know |__|
Placental problems (previa, abruption, etc.) |__|
N/A |__|
If POSTPARTUM, pregnancy outcome:
Live birth|__|
Other (specify) ___________________________ |__|
Still birth |__|
Don’t know |__|
Miscarriage |__|
N/A |__|
Pregnancy terminated |__|
D-13
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: STAFF COMPLETED WOMEN’S ITEMS
This is to be completed by project staff at 6 months post-Intake.
1.
2.
Is this woman pregnant, postpartum (less than 12 months since her last delivery), or both?
Pregnant |__|
Both Pregnant and Postpartum |__|
Postpartum |__|
Neither Pregnant nor Postpartum |__|
If PREGNANT, at what trimester of pregnancy is this woman?
First (week 1 to week 12) |__|
Don’t know |__|
Second (week 13 to week 26) |__|
N/A |__|
Third (week 27 to delivery) |__|
3.
4.
If PREGNANT, has this woman experienced any problems during pregnancy? Select all that apply.
Gestational diabetes |__|
Other (specify) __________________________ |__|
Preeclampsia or pregnancy induced hypertension |__|
None|__|
Sexually Transmitted Diseases (STDs) |__|
Don’t know |__|
Placental problems (previa, abruption, etc.) |__|
N/A |__|
If POSTPARTUM, pregnancy outcome:
Live birth |__|
Other (specify) __________________________ |__|
Still birth |__|
Don’t know |__|
Miscarriage |__|
N/A |__|
Pregnancy terminated |__|
D-14
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 |__|__| |__|__| |__|__|__|__|
WOMAN’S DISCHARGE DATE:
2 0
|__|__| |__|__| |__|__|__|__|
Discharge |__| PERSON COMPLETING
EVALUATION PHASE:
|_______________| GRANT#
TI |__|__|__|__|__|__|
DISCHARGE: STAFF COMPLETED WOMEN’S ITEMS
This is to be completed by project staff at discharge.
1.
Is this woman pregnant, postpartum (less than 12 months since her last delivery), or both?
Pregnant |__|
Neither Pregnant nor Postpartum |__|
Postpartum |__|
Both Pregnant and Postpartum |__|
2.
If PREGNANT, at what trimester of pregnancy is this woman?
First (week 1 to week 12) |__|
Don’t know |__|
Second (week 13 to week 26) |__|
N/A |__|
Third (week 27 to delivery) |__|
3.
4.
If PREGNANT, has this woman experienced any problems during pregnancy? Select all that apply.
Gestational diabetes |__|
Other (specify) __________________________ |__|
Preeclampsia or pregnancy induced hypertension |__|
None|__|
Sexually Transmitted Diseases (STDs) |__|
Don’t know |__|
Placental problems (previa, abruption, etc.) |__|
N/A |__|
If POSTPARTUM, pregnancy outcome:
Live birth|__|
Other (specify) __________________________ |__|
Still birth |__|
Don’t know |__|
Miscarriage |__|
N/A |__|
Pregnancy terminated |__|
D-15
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 |__|__| |__|__| |__|__|__|__|
WOMAN’S DISCHARGE DATE:
2 0
|__|__| |__|__| |__|__|__|__|
EVALUATION PHASE: 6 months post-Discharge |__| PERSON COMPLETING |_______________| GRANT# TI |__|__|__|__|__|__|
6 MONTHS POST-DISCHARGE: STAFF COMPLETED WOMEN’S ITEMS
This is to be completed by project staff at 6 months post-Discharge.
1.
If no followup was obtained, select reason why.
Refusal |__|
Unable to locate |__|
Incarcerated and unable to gain access |__|
Deceased |__|
2.
Readmitted to program with new admission replacing
prior admission |__|
Other: __________________ |__|
N/A |__|
Is this woman pregnant, postpartum (less than 12 months since her last delivery), or both?
Pregnant |__|
Neither Pregnant nor Postpartum |__|
Postpartum |__|
No followup obtained |__|
Both Pregnant and Postpartum |__|
3.
4.
If PREGNANT, at what trimester of pregnancy is this woman?
First (week 1 to week 12) |__|
Don’t know |__|
Second (week 13 to week 26) |__|
N/A |__|
Third (week 27 to delivery) |__|
No followup obtained |__|
If PREGNANT, has this woman experienced any problems during pregnancy? Select all that apply.
Gestational diabetes |__|
None|__|
Preeclampsia or pregnancy induced hypertension |__|
Don’t know |__|
Sexually Transmitted Diseases (STDs) |__|
N/A |__|
Placental problems (previa, abruption, etc.) |__|
No followup obtained |__|
Other (specify)___________________________|__|
D-16
5.
If POSTPARTUM, pregnancy outcome:
Live birth |__|
Other (specify)___________________________|__|
Still birth |__|
Don’t know |__|
Miscarriage |__|
N/A |__|
Pregnancy terminated |__|
No followup obtained |__|
D-17
Attachment D-4
Staff Completed Child Items
D-18
READMIT |__|
INITIALS |__|__|
DATE:
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 ||
PERSON COMPLETING
|_______________|
GRANT# TI |__|__|__|__|__|__|
INTAKE: STAFF COMPLETED CHILD ITEMS
This tool is to be completed by program staff for each minor child (under 18) of a mother receiving treatment services who is receiving
(or the mother anticipates will receive) services. This tool should be completed with the use of treatment records, maternal interviews,
and observations.
1.
Child Age
|__|__| years |__|__| months
2.
Was this child born premature (less than 37 weeks gestation)?
Yes |__|
3.
No |__|
Where was the child’s primary residence during the past six months?
Biological Mom & Dad |__|
Family Friends |__|
Biological Mom |__|
Foster |__|
Biological Dad |__|
Adoptive |__|
Grandparent(s) |__|
Other (specify) _________________ |__|
Biological Relatives |__|
4.
Will this child reside in this residential treatment facility with the mother?
Yes |__|
No |__|
Don’t know |__|
D-19
READMIT |__|
INITIALS |__|__|
DATE:
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: 3 mos post-Intake || PERSON COMPLETING
|_______________|
GRANT# TI |__|__|__|__|__|__|
3 MONTHS POST-INTAKE: STAFF COMPLETED CHILD ITEMS
This tool is to be completed by program staff for each child of a mother receiving treatment services who is receiving (or the mother
anticipates will receive) services. This tool should be completed with the use of treatment records, maternal interviews, and
observations.
1.
Child Age
|__|__| years |__|__| months
2.
Where was the child’s primary residence during the past six months?
Biological Mom & Dad |__|
Family Friends |__|
Biological Mom |__|
Foster |__|
Biological Dad |__|
Adoptive |__|
Grandparent(s) |__|
Other (specify) _________________ |__|
Biological Relatives |__|
3.
Has this child resided in this residential treatment facility with the mother?
Yes |__|
4.
No |__|
Don’t know |__|
If NO, on average, how often has this child visited the mother while she was staying in this residential treatment facility?
More than once a week |__|
Weekly |__|
2 – 3 times per month |__|
Monthly |__|
Less than monthly |__|
Never |__|
N/A |__|
D-20
READMIT |__|
INITIALS |__|__|
DATE:
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: 6 mos post-Intake || PERSON COMPLETING
|_______________|
GRANT# TI |__|__|__|__|__|__|
6 MONTHS POST-INTAKE: STAFF COMPLETED CHILD ITEMS
This tool is to be completed by program staff for each child of a mother receiving treatment services who is receiving (or the mother
anticipates will receive) services. This tool should be completed with the use of treatment records, maternal interviews, and
observations.
1.
Child Age
|__|__| years |__|__| months
2.
Where was the child’s primary residence during the past six months?
Biological Mom & Dad |__|
Family Friends |__|
Biological Mom |__|
Foster |__|
Biological Dad |__|
Adoptive |__|
Grandparent(s) |__|
Other (specify) _________________ |__|
Biological Relatives |__|
3.
Has this child resided in this residential treatment facility with the mother?
Yes |__|
4.
No |__|
Don’t know |__|
If NO, on average, how often has this child visited the mother while she was staying in this residential treatment facility?
More than once a week |__|
Weekly |__|
2 – 3 times per month |__|
Monthly |__|
Less than monthly |__|
Never |__|
N/A |__|
D-21
READMIT |__|
INITIALS |__|__|
DATE:
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: Discharge ||
PERSON COMPLETING
|_______________|
GRANT# TI |__|__|__|__|__|__|
DISCHARGE: STAFF COMPLETED CHILD ITEMS
This tool is to be completed by program staff for each child of a mother receiving treatment services who is receiving (or the mother
anticipates will receive) services. This tool should be completed with the use of treatment records, maternal interviews, and
observations.
1.
Child Age
|__|__| years |__|__| months
2.
Where was the child’s primary residence during the past six months?
Biological Mom & Dad |__|
Family Friends |__|
Biological Mom |__|
Foster |__|
Biological Dad |__|
Adoptive |__|
Grandparent(s) |__|
Other (specify) _________________ |__|
Biological Relatives |__|
3.
Did this child reside in this residential treatment facility with the mother?
Yes |__|
4.
No |__|
Don’t know |__|
If NO, on average, how often did this child visit the mother while she was staying in this residential treatment facility?
More than once a week |__|
Weekly |__|
2 – 3 times per month |__|
Monthly |__|
Less than monthly |__|
Never |__|
N/A |__|
D-22
READMIT |__|
INITIALS |__|__|
DATE:
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: 6 mos post-Discharge || PERSON COMPLETING
|_______________|
GRANT# TI |__|__|__|__|__|__|
6 MONTHS POST-DISCHARGE: STAFF COMPLETED CHILD ITEMS
This tool is to be completed by program staff for each child of a mother receiving treatment services who is receiving (or the mother
anticipates will receive) services. This tool should be completed with the use of treatment records, maternal interviews, and
observations.
1.
If no followup interview was obtained, select all reasons that apply.
Unable to locate |__|
Parental rights terminated |__|
Mother refused |__|
Child did not receive services |__|
Caregiver refused |__|
Deceased |__|
Child living with someone other than the mother |__|
Other: ____________________ |__|
Mother lacks legal custody (include if custody is
N/A |__|
temporarily on hold) |__|
2.
Child Age
|__|__| years |__|__| months
No followup obtained |__|
3.
Where was the child’s primary residence during the past six months?
Biological Mom & Dad |__|
Family Friends |__|
Biological Mom |__|
Foster |__|
Biological Dad |__|
Adoptive |__|
Grandparent(s) |__|
Other (specify) _________________ |__|
Biological Relatives |__|
No followup obtained |__|
| File Type | application/pdf |
| File Title | Attachment D - Instruments for Project Staff |
| Author | Victoria Castleman |
| File Modified | 2010-09-01 |
| File Created | 2010-09-01 |