Form Instrument for Cli Instrument for Cli Instrument for Clinical Director

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ATTACHMENT G:

INSTRUMENT FOR CLINICAL DIRECTOR/SUPERVISOR

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Site Visit Protocol-Clinical Director/Supervisor Interview

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Attachment G-1

Site Visit Protocol – Clinical Director/Supervisor Interview

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TI #_________

Clinical Director/Supervisor Interview*
2/15/10

[Words in italics are notes to the interviewer and are not meant to be read aloud. The optional comments column can
include evidence for the provision of specific services.]
Grantee Name:

______________________________________________

Clinical Director/ Supervisor Name:

_____________________________________________

Clinical Director/ Supervisor Gender:

M

F

Clinical Director/ Supervisor Phone Number (In Case Follow-Up Is Needed): _____________________
Interviewer Names and Role (1=Primary Interviewer, 2=Notes, 3=Also Present):
______________________
______________________
__________________
Date Of Interview:_____ _____ _____
Interview Start and End Times: _________

_________

Section 1. Respondent Background
[If DK From Introductory Phone Protocol:]
First, I’d like to find out a little about your background and your job here.
1.1 How long have you worked with the PPW program at _[Grantee Name]?
Years _________ Months_______
1.2 What positions have you held here during this time?
[Record All Positions At PPW Program And Start/End Dates Below.]
Position
Start Date

End Date

1.3 Do you know generally about the services offered to PPW client’s children here, or is there someone else (i.e.,
Children’s Services Coordinator) that we should speak with about children’s services?
Yes→Ask Questions In Section 12
No → Name: _________________________________ Ask Named Individual Questions In Section 12

* Based on (1) Treatment Guidelines for Gender Responsive Treatment of Women with Substance Use Disorders developed by the Women's Services Practice
Improvement Collaborative (WSPIC) of the Connecticut Department of Mental Health & Addiction Services, facilitated by the Connecticut Women's Consortium and (2)
Protocols used with NIDA grant R01 DA15094-01, Effectiveness of Specialized Treatment for Women with Children.

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1.4 What are your current responsibilities?

1.5 Are you responsible for any other programs/modalities in addition to the PPW grant?
No→Skip Next Item
Yes→Please describe.
If Yes Above, on average, approximately what percentage of your time each month is devoted to the PPW
program?
______ %

1.6 Please tell me about your educational background and credentials including any licenses or certifications.
1.7 About how long have you worked in substance abuse and/or mental health treatment?
_____ Years ______ Months
a. If Greater Than 0 Months, please describe your professional experience related to addictions, mental health, health
or other healthcare.
[Description Of Professional Experience Related To Addictions, Mental Health, Or Other Healthcare.]
Position
Facility Type
Duration (In Years)

Section 2: Treatment Philosophy/Characteristics/Facility
This study focuses on women and their children who have received treatment (or are currently receiving treatment) in your
PPW program since your grant started.
[Skip 2.1 If Already Have This Information From The Program Director].
2.1 Can you think of any general changes that have occurred since your PPW grant started in the following areas?
a. The client population served here?

b. Program staffing?

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c. Services offered?

d. Changes in the community where your PPW program is located that have influenced the services you provide?

e. Other program matters?

Now, I would like to ask you some questions about your PPW program’s approach to treatment and the treatment philosophy
of your program.
2.2 Can you please tell me a little about how your PPW clinical program is structured?

a. Does your PPW program have phases of treatment for clients (e.g., women receive specific services for allocated
amounts of time and then receive different services; women are grated specific privileges and earn more privileges as
goals are met)
Yes
No→Go To 2.3
Other, Specify:

b. How is each phase characterized? (e.g., privileges, time in treatment, treatment milestones, patient-to-staff ratio)?

c. What is required to progress through phases?

d. What might cause a demotion in phase?

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2.3 Please tell me about the treatment model/philosophy here that is used to treat clients in the PPW program. Probe: 12step, Contingency management, etc. [Check All That Apply]
12-Step
Met / Motivational Enhancement
Contingency Management
Cognitive-Behavioral
Other, Specify:
2.4 Is there a written copy of the treatment model/philosophy used for clients?
No
Yes → Request A Copy [Check If Copy is Provided ]
DK
2.5 Does your PPW program use any structured treatment protocols or manuals? (e.g., Probe: CSAT TIPs or the approaches
listed in NIDA’s Principles of Effective Drug Treatment?)
No→Skip Next Item
Yes – Which Ones?
Request A Copy [Check If Copy is Provided ]
DK→Skip Next Item
a. What percentage of the staff received training on these treatment protocols or manuals?
1
2
3
4
5
<5% 25% 50%

75%

>95%

b. To what extent are treatment services delivered in manner prescribed by the treatment protocols or manual?
1

<5%

Rarely/
none

2

25%

Less than
half of services

3

50%

About
half

4

5

75%

More than
half of services

>95%

Almost all/
all services

2.6 Have the treatment model/philosophy or treatment protocols/ manuals been modified or adapted since the PPW grant
started?
No→Skip Next Item
DK→Skip Next Item
Yes – Which?
Treatment Model/Philosophy
Treatment Protocols/Manuals
a. Describe adaptations and explain why the modifications/adaptations were necessary or desirable

2.7 What is your program’s approach to relapse during treatment? [Responses Can Be Used As Probes]
Any substance use leads to automatic discharge
Determined on a case-by-case basis
Other, Specify:

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a.

Is this a formal or informal policy?
Formal
Informal
Other, Specify:

2.8 What is the treatment re-entry policy after premature discharge from the PPW program? [Responses Can Be Used As
Probes]
Mandatory delay before re-entry, Specify duration and conditions:
Determined on a case-by-case basis
Other, Specify:
Now I’m going to ask about the characteristics of the treatment provided in your PPW program. Please think about the
following statements and indicate how strongly you agree or disagree about how each statement describes the program.

2.11 Treatment is strength (asset) based,
with ongoing opportunities for women to
experience, practice and explore positive
capabilities.
(Describe how evidence of how client
strengths are used in program)
2.12 Treatment incorporates unique
cultural characteristics, strengths and
potential supports for each participant.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

-5-

Strongly
Agree

Agree

2.10 Approaches are respectful,
supportive and empowering, not
authoritarian, attacking or demeaning.
(Particularly how clients are dealt with
when they are non-compliant or
engaged in treatment interfering
behaviors)

Undecided

2.9 The therapeutic environment is safe,
inviting, non-institutional, homelike,
welcoming, with appropriate cultural
features. (This refers primarily to physical
features of setting)

Strongly
Disagree

Program Characteristic

Disagree

Rating
Optional Comments

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Now I’m going to ask you about the PPW facility and the general program environment. Please think about the following
statements and indicate how strongly you agree or disagree about how each statement describes the program.

2.13 The PPW program is located in a
safe neighborhood in terms of crime and
drug use.

Strongly
Agree

Agree

Undecided

Disagree

General Program Environment

Strongly
Disagree

Response

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

2.19 The PPW visiting hours are
sufficient (in your clinical opinion).

1

2

3

4

5

2.20 In general, PPW clients feel that
PPW visiting hours are sufficient.

1

2

3

4

5

2.14 The PPW program
environment/setting is safe and secure.
That is, entry to program is protected, and
security procedures in place.
2.15 Some common area(s) of the facility
are accessible ONLY to women.
2.16 Smoking areas are supervised.
2.17 The race/ethnicity of staff reflects
the cultural diversity of the clients.
2.18 Program includes positive cultural
experiences and materials.

4

5

Optional Comments

If 4 or 5, describe.

To what extent do the following statements describe the PPW program and the services provided to support client’s
children?
2.21 There is comfortable play space for
children visiting the program.

1

2

3

4

5

2.22 There are areas for mothers and
visiting children to interact naturally.

1

2

3

4

5

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Now, I’m going to ask about the caseloads of clinical staff that treat PPW clients.
2.23 What is the current average caseload per full-time counselor?
DK
_______ Clients Per Counselor
2.24 How frequently are clients switched from one counselor to another during treatment?
Never
Rarely
Sometimes
Often
Always
a. If Sometimes, Often, Always why are clients switched to another counselor?
2.25 Do you have case managers?
No Skip Next Item
Yes
2.26 What is the current average caseload per case manager?
DK
_______ Clients Per Case Manager
2.27 For an average client, about how many individual sessions does she have with her counselor each week (where the
individual session lasts 15 minutes or more)?
<1 Sessions Per Week
1 Session Per Week
>2 Sessions Per Week
Varies, Specify:
2.28 On average, about how long does each individual session with her counselor last?
DK
______ Minutes
2.29 Are counselors available to clients by appointment only, as needed during the day shift, 24 hours a day, or on some
other schedule?
By Appointment Only
As Needed On Day Shift
24 Hours A Day
Some Other Schedule Specify:

Section 3: Target Population
I would like to find out about the clients treated in your PPW program since the beginning of the grant.
3.1 Are some women given priority for admission to PPW?
No
Yes
DK

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a. If Yes, what types of women are given priority? [Don’t Use Listed Responses As Probes]
IV Drug Users
Patients in Unsafe Living Situations (e.g., domestic violence)
Parenting Patients
Repeat Patients (who have already been in the program)
Court-Ordered Patients
Other, specify
None
b.

Why are they given priority?

Does the PPW program provide treatment to
clients who…

Response

3.2 .... are currently suicidal? (i.e.,
experiencing/expressing suicidal
thoughts)

DK
No
Yes

3.3 .. have a history of prior violent behaviors?

DK
No
Yes

3.4 .. have an acute psychiatric condition?
(Definition: psychiatric problem different from
substance abuse needing immediate
attention)

DK
No
Yes
If Yes, are there any
psychiatric conditions you
exclude?
DK
No
Yes
If Yes, specify:

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Optional Comments

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Does the PPW program provide treatment to
clients who…

Response

Optional Comments

DK
No
Yes
If Yes, are there any
conditions you exclude?

3.5 .... have an acute medical condition?

DK
No
Yes
If Yes, specify

(Definition: medical symptoms needing
immediate attention)

On average, about what percentage of the clients treated in the PPW program …
3.6 .... are pregnant?

1

2

3

4

5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%

25%

50%

75%

≥ 95%

3.7…are postpartum?
3.8 .... are currently involved with child welfare/
Child Protective Services?

Section 4.

Assessment and Engagement

I’m going to start by asking you about the assessment and engagement process experienced by clients in your PPW program.
4.1 Do you use assessment forms in addition to GPRA?
DK→Go To 4.4
No→Go To 4.4
Yes→Request Copy [Check If Copy Provided ]
4.2 May I please have a copy of the treatment planning forms?
NA – Don’t Use Treatment Planning Forms
No
Yes→[Check If Copy Provided ]
4.3. Is the assessment process sensitive to client’s possible history of sexual abuse or domestic violence (i.e., sensitivity to
re-traumatization)?
No
Yes→Please explain how the process is sensitive to re-traumatization.

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Please think about the following statements and indicate how strongly you agree or disagree with each statement.

Strongly
Agree

4.7 Accommodations are made so that nonEnglish speaking clients can access written
materials.

Agree

4.6 When a client has difficulty engaging in
the assessment process, the program uses
outreach and other efforts to get the client
involved in the treatment program.

Undecided

4.5 If a client had to wait longer than one week
to enter the program, there were regular,
ongoing contacts with her until she entered
program.

Disagree

4.4 Clients had to wait less than one week to
enter the program.

Strongly
Disagree

Response

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Optional Comments

NA

During the initial assessment with clients, to what extent are the following areas addressed…

4.12 …concerns for her safety?

Strongly
Agree

4.11 …history of domestic violence?

Agree

4.10 …history of grief and loss?

Undecided

4.9 …other relationships and social support
resources outside of this treatment program?

Disagree

4.8 …parenting skills?

Strongly
Disagree

Response

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

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Optional Comments

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Never

Rarely

Sometimes

Often

Always

Response

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

4.13 …sexuality, sexual orientation, and
related concerns?
4.14 …stage of change?
4.15 …life skills such as paying bills, shopping
for food, managing a budget, or renting an
apartment?
4.16 …vocational needs?
4.17 …housing needs?
4.18 …spiritual, religious, or cultural needs?
4.19 …gambling problems?
4.20 … physical abuse , sexual abuse, and/or
PSTD using a standardized tool or written
protocol

Optional Comments

How is stage of change measured?

Section 5. Treatment Planning
Now I’m going to ask you about the treatment plans for clients treated in your PPW program.
Treatment Planning

Response

Optional Comments

About what percentage of client’s treatment plans…
5.1 .... …include integrated / coordinated
substance use and mental health objectives (i.e.,
they are kept separate or parallel)?
5.2 …contain mental health objectives that
include strategies to reduce specific symptoms?
5.3 …list the client’s strengths and assets and
how these will be used to achieve the client’s
recovery objectives?
5.4 .... …include the client as an active
participant in the process of developing recovery
objectives?

1

2

3

4

5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%

25%

50%

75%

≥ 95%

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Section 6: Specific Services Available During Treatment
Now I would like to ask you about the specific services offered to clients in your PPW program.
Treatment Services

Response

Optional Comments

On average, what percentage of ALL groups attended by clients in your PPW program are…
6.1
…led by a female (counselor, therapist,
tech, or case manager)?

1

2

3

4

5

< 5%

25%

50%

75%

≥ 95%

About what percentage of the clients in your PPW program…
6.2
…receive counseling related to PTSD or
trauma such as sexual abuse and domestic
violence?
6.3
…receive counseling or training about
healthy relationships and how to avoid
unhealthy relationships?
6.4
…receive assertiveness and/or selfefficacy training?
6.5 …make use of clearly-established peer
supports within the program?
(Probe: …such as women in more advanced
levels of treatment mentoring those beginning)
6.6
…receive counseling or education about
eating problems such as overeating, binge
eating, or purging?
6.7
…receive medical/health information
relevant to women’s issues (e.g., family
planning, contraception, or education about
Fetal Alcohol Spectrum Disorders?)
6.8
…education about risky sexual
behaviors, safer sex, or STDs?
6.9
…receive physical health screening that
is gender specific? (including GYN screening?)

6.10 …receive STD or pregnancy testing?

6.11
…receive assistance to interface with
Child Protective Services or child welfare?

1

2

3

4

5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%

25%

50%

75%

≥ 95%

1

2

3

4

5

< 5%

25%

50%

75%

≥ 95%

1

2

3

4

5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%

25%

50%

75%

≥ 95%

1

2

3

4

5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%

25%

50%

75%

≥ 95%

1

2

3

4

5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%

25%

50%

75%

≥ 95%

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Treatment Services

Response

6.12 ...receive educational services (e.g., GED
preparation)?
6.13 .. …receive help developing a vocational
plan?
6.14 …receive vocational training while
receiving treatment?
6.15 .. …receive
assistance
finding
employment in the community?

paid

6.16 ...receive help interacting with the welfare
system including WIC, SSD, and Medicaid?
6.17 …receive family therapy incorporating
significant others or family members identified
by the client?
(The family therapy could include family
conferences led by the primary counselor.)

Optional Comments

1

2

3

4

5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%

25%

50%

75%

≥ 95%

1

2

3

4

5

< 5%

25%

50%

75%

≥ 95%

While in your PPW program, about what percentage of the clients…
6.18 ,..participate in (semi-)structured physical
activities?
6.19 .. ...participate in structured social or
recreational activities?
6.20 ...participate in cultural or spiritual
activities?
6.21 …participate in parenting classes or other
education regarding their relationship or
reunification with their children?
6.22 .. …receive transportation supports (like
rides, tokens, or cards) to appointments?

1

2

3

4

5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%

25%

50%

75%

≥ 95%

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6.23 For an average client, about how many group therapy sessions does she attend per week? (Do not include group
education sessions here.)
DK
______ Sessions Per Week
6.24 On average, about how long does a group therapy session last?
DK
______ Minutes

6.25 For an average client, about how many education groups does she attend per week?
DK
______ Sessions Per Week
6.26 On average, about how long does an average education group last?
DK
______ Minutes
Now I’d like to ask you about the programs and services offered to clients in your PPW program since the grant started. I
will ask you whether services are offered onsite and also if they are offered offsite or through coordinated referrals.
6.27 Do you currently offer to clients in your PPW program the ability to obtain or refill medications onsite while
treatment?
Yes
No
a. If No, is this available offsite or through coordinated referrals?

6.28 Are there medications or types of medications clients are not able or allowed to refill while they are in PPW treatment?
Yes
a. If Yes, please describe.
No
6.29 Do you currently offer to clients in your PPW program psychiatric medication consultation onsite?
Yes
No
a. If No, is this available offsite or through coordinated referrals?

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6.30 Do you currently offer to clients in your PPW program prenatal/perinatal services onsite?
Yes
No
a. If No, is this available offsite or through coordinated referrals?

6.31 Can care be provided in conjunction with opiate substitution treatment involving methadone or Suboxone®, if
appropriate? [Participation in such a program is not a basis for exclusion from treatment program.]:
Yes
No
DK

6.32 Does treatment incorporate the use of other medications for substance abuse problems, such as disulfiram (antabuse),
naltrexone (revia or vivitrol), acamprosate (campral), or others?
Yes
No
DK
6.33 About how often are direct services to women’s other family members (not just children) provided onsite, within your
PPW program? [This refers to the treatment needs of the other family members apart from issues directly related to the
woman]
Never
Rarely
Sometimes
Often
Always
6.34 About how often are women’s other family members (not just children) given referrals for services or have services
arranged for them? [This refers to treatment needs of the other family members apart from issues directly related to the
woman.]
Never
Rarely
Sometimes
Often
Always

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Now I’d like to know more about how offsite providers (or specialists who come to the facility to see women on a referral
basis) and staff in your PPW program communicate.
6.35 How do offsite and onsite providers communicate about the clients served? [Probe: Do they have joint case
conferences?)

6.36 Please describe the level of communication or case conferencing between offsite providers (or specialists who come to
the facility to see clients on a referral basis) and staff in your PPW program about the specific clients served.

Now I’d like to find out about off-site and overnight privileges offered by your PPW program
6.37 Do clients in your PPW program get off-site or overnight privileges?
Yes
No→Go To Section 7
DK→Go To Section 7
6.38 How is it determined if/when clients get overnight privileges?
Later Phase
Live Far Away
Other, Specify:
NA

Section 7. Discharge Planning

Always

Often

Sometimes

Ra rely

Discharge Planning

Never

Now I’m going to ask you about discharge planning for the clients treated your PPW program.

By the time women are discharged from your PPW program, about how often…
7.1 …have they been taught about women’s
self-help groups (like AA, NA, or other
groups)?

1

2

3

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4

5

Optional Comments

7.4 …have they received help connecting to
social support systems such as recreational or
religious groups?
7.5 …have they received help reconnecting to
estranged family members or significant others?

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Always

Often

7.3 …have they been connected to recovery
supports in the community such as advocacy
groups, domestic violence programs, or other
women-focused programs?

Sometimes

7.2 …have they attended off-site self-help
groups for women?

Ra rely

Discharge Planning

Never

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Optional Comments

Section 8: Post-Treatment Housing Services
Now I’d like to talk about post-treatment and transitional housing services provided to clients after completing your PPW
program.
Response

Post-Treatment Housing Services
8.1
About what percentage of clients does
the PPW program help develop a concrete and
specific post-treatment housing plan that will
support recovery?

Optional Comments

1

2

3

4

5

< 5%

25%

50%

75%

≥ 95%

Upon completing PPW treatment, about what percentage of clients actually go…
8.2 …into an institution (hospital, inpatient or
other residential program, or jail/prison)?
8.3 …into transitional housing?
8.4 …into a living situation where drugs or
alcohol are abused in the home?
8.5 .... …into a potentially abusive domestic
situation?

1

2

3

4

5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%
1

25%
2

50%
3

75%
4

≥ 95%
5

< 5%

25%

50%

75%

≥ 95%

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Section 9: Recovery Support/Continuing Care Services
Now I would like to ask you about any continuing care services available to the clients in your PPW program.
9.1 Does your PPW program offer recovery support/continuing care services to clients who graduate?
No→Go To Section 10
DK→Go To Section 10
Yes→Describe.
9.2 Is continuing care mandatory for all clients who do not go to another treatment program upon discharge?
No
DK
Yes
9.3 What determines the duration, frequency, and content of continuing care?

9.4 What outreach practices does the PPW program use for following up with clients who do not show up for continuing
care?

a. Are there official outreach policies?

9.5 Do you or anyone in the program provide transportation for continuing care?
Yes, Respondent
Yes, Someone else in Program
No→Skip Next Item
DK
9.6 Do PPW counselors meet clients off-site for continuing care?
No→Go To 9.10
DK→Go To 9.10
Yes
9.7 On average, about how much time do counselors spend each month meeting clients offsite for continuing care?
________ Days
DK
9.8 How do your responsibilities change during continuing care? [Probe for Counseling, Case Management, etc.]

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Section 10. Program Challenges
Now, I would like to understand some of the challenges that your PPW program has faced since your grant started. I’m
going to read a list of areas that are often challenging for programs. Please tell me how much of a challenge this has been for
this program on a scale of 1 to 5, where 1=Not at all a challenge and 5=Very much a challenge. Where this has been a
challenge, I would like to know what the nature of the challenge has been and whether you think it was successfully resolved.
How much of a challenge have the following areas been since your grant started?
IF A=2-5:

10.1 Finding and
keeping qualified staff

10.2 Facilities

10.3 Meeting clients’
needs for services

1

1

1

2

2

2

3

3

3

4

4

4

IF A = 2-5:

Very
Much

(B) Description/Source of Challenge
[Don’t Read Categories]
Much

Somewhat

Little

Program Challenge
Area

Not at all

(A)
Rating

5

5

5

Staff Turnover
Limited Staff (Training, Qualifications)
Not Enough Staff
Finding Qualified Staff
Low Pay
Other, Specify:

Ongoing
Resolved
(Specify)

Old Or Run-Down
Insufficient Space
Access To Community/Public Transport
Neighborhood Iffy (Drugs, Crime)
Other, Specify:

Ongoing
Resolved
(Specify)

Meeting Mental Health Needs
Clients Have Too Many Needs
Voc Training/Job Placement Hard
Not Enough Women’s Beds
Keeping Enough Women In Tx
Safety (Emotional, Physical)
Insufficient Childcare
Medical Issues
Other, Specify:

Ongoing
Resolved
(Specify)

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IF A=2-5:

(A)
Rating

10.5 Providing services
for children within your
PPW program

10.6 Having prenatal or
perinatal services
available ONSITE

10.7 Client satisfaction

Little

Somewhat

Much

Very
Much

10.4 Visitation with
children (who are not in
treatment with mother)

Not at all

Program Challenge
Area

(B) Description/Source of Challenge
[Don’t Read Categories]

1

2

3

4

5

1

1

1

2

2

2

3

3

3

4

4

4

5

5

5

IF A = 2-5:

Children Live Far Away
Cps/Others Won’t Bring Them
Other, Specify:

Ongoing
Resolved
(Specify)

Not Enough Child Beds
Accommodating Older Boys
Accommodating Older Girls
Child Behavior Problems
Meeting Children’s Therapeutic Needs
Other, Specify:

Ongoing
Resolved
(Specify)

Expensive W/ Inadequate Reimbursement
Need Is Variable So Hard To Keep
Resources/Linkages Fresh
Other, Specify:
NA

Ongoing
Resolved
(Specify)

Clients Complain About:
Food
Physical Accommodations
Staff
Prog Rules, Restrictions, Requirements
Wanting More Services Or Help
Don’t Want To Be Here, Tx Coerced
Everything - Impossible To Please
Other, Specify:

Ongoing
Resolved
(Specify)

10.8 What services are not currently provided to PPW clients and/or their children that you think would enhance treatment
for clients, children and/or families?

10.9 Are there any topics that you would like to see covered in a staff training/professional development activity?
No
Yes→Describe.

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10.10 Of all of the services your program provides, which do you think have had the most influence in:
a. Decreasing client’s substance use? Please explain how or in what way?

b. Increasing safe and healthy pregnancies/improved birth outcomes? Please explain how or in what way?

c. Improving mental health of clients and their children? Please explain how or in what way?

d. Improving physical health of clients and their children? Please explain how or in what way?

e. Improving family functioning? Please explain how or in what way?

f. Decreasing involvement/exposure to crime, violence, sexual/physical abuse, and child abuse/neglect? Please
explain how or in what way?

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g. Improving economic/housing stability? Please explain how or in what way?

Section 11.

Respondent Demographic Information

Before we finish, I would like to ask you a few questions about your demographic characteristics.
11.1 Do you consider yourself to be Hispanic or Latino/a?
Yes
No
DK/Refused
11.2 What race or ethnic backgrounds do you most identify with? You can choose all that apply. Would you say…
…American Indian or Alaska Native,
…Asian,
…Black or African American,
…Native Hawaiian or other Pacific Islander, and/or
…White?
DK/Refused
11.3

I am going to list some age categories. Would you say you are…
... 18-25,
…26-34,
…35-44,
…45-54,
…55-64, or
…65 or older?
Refused

INTERVIEWER SCRIPT: That is all of the questions that I have for you. Do you have any questions for me or would you
like to tell me about any other issues that you think are important to understanding the program or the services that you
provide? Thank you.

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[Section 12 is to be completed by the person indicated in item 1.3. Skip to item 12.5 if Clinical Director completes this
section.]

Section 12.

Children’s Services

Grantee Name:

______________________________________________

Children’s Coordinator Name:
Children’s Coordinator Gender:

_____________________________________________
M

F

Children’s Coordinator Phone Number (In Case Follow-Up Is Needed): __________________________
Interviewer Names and Role (1=Primary Interviewer, 2=Notes, 3=Also Present): __________________
__________________
_________________
Date of Interview:

______________________

Interview Start and End Times: _________

_________

You were indicated by the [Clinical Director] as being the person most knowledgeable about children’s services being
offered in your PPW program.
Respondent Background
First, I’d like to find out a little about your background and your job here.
12.1 How long have you worked with the PPW program at _[Grantee Name])?
Years _________ Months_______
12.2 What positions have you held here during this time?
[Record All Positions At PPW Program And Start/End Dates Below]
Position
Start Date

12.3 What are you current responsibilities?

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End Date

G-26

12.4 About how long have you worked in substance abuse and/or mental health treatment?
_____ Years ______ Months
a. If Greater Than 0 Months, please describe your professional experience related to addictions, mental health, health
or other healthcare.
[Description Of Professional Experience Related To Addictions, Mental Health, Or Other Healthcare.]
Position
Facility Type
Duration (In Years)

Services Provided to Children Living with Mothers in PPW Program
Now I’m going to ask you about the services your PPW program provides for the children who live with their mothers in
your PPW program.
12.5 On average, about how much time do on-site staff spend per client on childcare and other activities related to children
living with their mothers in your program?
_____ Hours Per Client
DK
12.6 Are there limits such as the child’s age, the number of children, and/or how long the child can stay with the mother in
your program?
Girl’s age: ______________
Boy’s age: ______________
# per woman: ____________
Stay only a few days at a time
Other, Specify:
12.7 Does your PPW program provide any services, in addition to childcare, to women’s children who live with them in
your Program?
No
Yes
a. If Yes, what types of specialized services are offered (i.e., counseling, play therapy, and/or education groups)?

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b. If Yes, is there a standardized treatment approach to the children’s services (i.e., treatment manuals, protocols,
specific staff training, etc.)?
No
Yes (please describe)

12.8 Are the children who are living with their mothers in your program screened or assessed for behavioral health and
developmental challenges?
No
Yes
a. If Yes, does this screening/assessment process take place onsite, offsite, or both?
Onsite
Offsite
Both
Other, Specify:
b.

If Yes, please describe the screening/assessment process (e.g., what types of behavioral health/developmental
challenges are assessed?

12.9 Approximately what percentage of children living in your PPW program with their mothers receive joint services for
the child and mother together such as family therapy, individual parenting classes, etc.?
1
2
3
4
5
<5% 25%

50% 75% ≥95%

12.10 Do these services take place onsite, offsite, or both?
Onsite
Offsite
Both
NA
Other, Specify:
12.11 On average, about how much time do women and their children spend in child/mother joint activities each week?
Please don’t count time spent in regular individual counseling. (Answer just for women who receive these services.)
______ Hours Per Week
DK
NA

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Now I’m going to ask you about your PPW program’s approach to the client’s children who are not living with them in your
program and other family members.
12.12 Are client’s children who are not living with their mothers in your program but for whom the mother still has custody,
screened or assessed for behavioral health and developmental challenges?
No
Yes
a. If Yes, does this screening/assessment process take place onsite, offsite, or both?
Onsite
Offsite
Both
Other, Specify:

b. If Yes, please describe the screening/assessment process (e.g., what types of behavioral health/developmental
challenges are assessed?

12.13 About how often do women have access to their children during PPW treatment via visits, phone, or email?
As much as the mother wants
Once per day
Multiple times per week
Once per week
At least once per month but less than weekly
Not at all
Other, Specify:

[Skip Remaining Items If Clinical Director Completed Above Section]

Respondent Demographic Information

Before we finish, I would like to ask you a few questions about your demographic characteristics.
12.14 Do you consider yourself to be Hispanic or Latino/a?
Yes
No
DK/Refused
12.15 What race or ethnic backgrounds do you most identify with? You can choose all that apply. Would you say…
…American Indian or Alaska Native
…Asian
…Black or African American
…Native Hawaiian or other Pacific Islander
…White
DK/Refused

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12.16 I am going to list some age categories. Would you say you are…
... 18-25
…26-34
…35-44
…45-54
…55-64
…65 or older
Refused
Interviewer Script: That is all of the questions that I have for you. Do you have any questions for me or would you like to
tell me about any other issues that you think are important to understanding the program or the services that you provide?
Thank you.

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