Form Instrument for Cou Instrument for Cou Instrument for Counselor

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ATTACHMENT H:

INSTRUMENT FOR COUNSELOR

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Site Visit Protocol-Counselor Interview

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Attachment H-1

Site Visit Protocol – Counselor Interview

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TI # __________

Counselor Interview*
2-8-10

[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:

______________________________________________

Counselor Name:

______________________________________________

Counselor Gender:

M

F

Counselor 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 What are your current responsibilities?

* 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 Do you work in other programs aside from the PPW program
No→Skip Next Item
Yes→Describe.
a. [If Yes Above], on average, approximately what percentage of your time each month is devoted to the PPW program?
______ %
1.5 Please tell me about your educational background and credentials including any licenses or certifications.

1.6 About how many years of counseling experience in total would you say that you have?
_____ 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)

1.7 Is your level of experience and role typical of other counselors at this facility?
Yes
No
a. If No, how does it differ?

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. Now I would like to ask you some questions about your PPW program’s approach to treatment.

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2.1 Have you received any training from this program in a specific clinical approach (or treatment philosophy) focused on
working with these clients?
No
Yes→Please describe the clinical approach/treatment philosophy

2.2 Are there specific treatment protocols/manuals used in the program?
No
Yes→Describe

a.

If Yes above, to what extent do you use these protocols/manuals with clients in your caseload?
Never
Rarely
Sometimes
Often
Always

2.3 Have you received training from this program in areas related to your work with clients (separate from the program’s
treatment model)?
No
Yes
a. What were the topics of these trainings

2.4 Are there any topics that you would like to see covered in a training/professional development activity by this program?
No
Yes Describe.

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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.

(Particularly how clients are dealt with
when they are non-compliant or
engaged in treatment interfering
behaviors)
2.7 Treatment is strength (asset) based,
with ongoing opportunities for women
to experience, practice and explore
positive capabilities.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Strongly
Agree

Agree

2.6 Approaches are respectful, supportive
and empowering, not authoritarian,
attacking or demeaning.

Undecided

2.5 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

(Evidence of how client strengths are
used in program)
2.8 Treatment incorporates unique cultural
characteristics, strengths and potential
supports for each participant.

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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.

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

Strongly
Agree

Agree

Disagree

Strongly
Disagree

General Program Environment

Undecided

Response

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

2.13 The race/ethnicity of staff reflects the
cultural diversity of the clients.

1

2

3

4

5

2.14 Program includes positive cultural
experiences and materials.

1

2

3

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

1

2

3

4

5

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

1

2

3

4

5

2.10 The PPW program environment
/setting is safe and secure. That is,
entry to program is protected, and
security procedures in place.
2.11 Some common area(s) of the facility
are accessible ONLY to women.
2.12 Smoking areas are supervised.

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?
2.17 There is comfortable play space for
children visiting the program.

1

2

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

1

2

3

3
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4

4

5

5

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Section 3. Responsibilities
Now I would like to ask you about your responsibilities within this program.
3.1 How many clients do you currently have in your caseload?
____________ Clients
3.2 How frequently are clients switched from one counselor to another during treatment?
Never
Rarely
Sometimes
Often
Always
a. If Sometimes, Often, or Always why are clients switched to another counselor?

3.3 When do you first meet with or begin taking care of the PPW clients?
… Before Admission
… At Admission
… After Admission
... Other, Specify:

SERVICE

Response

Do you provide….

3.4 …individual counseling?

3.5 …family counseling or conferences?

3.6 …group therapy?

3.7 …group education?

3.8 …child counseling?

TIME PROVIDING SERVICE
If Yes, what percentage of your time
per week do you spend providing …

No
Yes

1

2

3

4

5

<5% 25% 50% 75% ≥95%

No
Yes

1

2

3

4

5

<5% 25% 50% 75% ≥95%

No
Yes

1

2

3

4

5

<5% 25% 50% 75% ≥95%

No
Yes

1

2

3

4

5

<5% 25% 50% 75% ≥95%

No
Yes

1

2

3

4

5

<5% 25% 50% 75% ≥95%
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SERVICE

Response

Do you provide….

TIME PROVIDING SERVICE
If Yes, what percentage of your time
per week do you spend providing …

No
Yes

3.9 …Intake Assessments?
3.10 …Case Management (E.G., Helping
Clients Find And Access Resources In
The Community Including Helping Them
Make Calls, Etc)?
3.11 …Any other type of counseling for the
PPW program?
Please Specify:

1

2

3

4

5

<5% 25% 50% 75% ≥95%

No
Yes

1

2

3

4

5

<5% 25% 50% 75% ≥95%

No
Yes

1

2

3

4

5

<5% 25% 50% 75% ≥95%

3.12 In a typical week what percent of your time is spent receiving supervision?
1

2

3

4

<5% 25% 50% 75%

5
≥95%

3.13 Does the PPW program have any agreements with other agencies to provide counseling services/sessions outside of
this facility?
No
Yes
a. If Yes, describe.

3.14 Do you or any other program staff provide transportation to other agencies for clients who are in the PPW program?
Yes – Respondent or another Counselor
Yes –Someone else in Program
No (Even if join them on public transportation) →Go To 3.16
3.15 Do you attend offsite appointments with PPW clients?
No→Go To Section 4
Yes→
a. If Yes, what determines when you go with them?

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Section 4. 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…
4.1 …include integrated / coordinated substance
use and mental health objectives (i.e., they
are kept separate or parallel)?
4.2 …contain mental health objectives that
include strategies to reduce specific
symptoms?
4.3 …list the client’s strengths and assets and
how these will be used to achieve the
client’s recovery objectives?
4.4 …include the client as an active participant
in the process of developing recovery
objectives?

1

2

3

4

5

<5% 25% 50% 75% ≥95%
1
2
3
4
5
<5% 25% 50% 75% ≥95%
1

2

3

4

5

<5% 25% 50% 75% ≥95%
1

2

3

4

5

<5% 25% 50% 75% ≥95%

Section 5. Treatment Services
Now I’m going to ask you about clients’ access to counseling and client monitoring.
5.1 Are clients required to see you?
No
Yes
Sometimes→Describe.
Dk

Response
Sometimes

Often

Always

5.3 …do you initiate contact with clients?

Rarely

5.2 …do PPW clients initiate contact with you
outside of regularly scheduled meetings?

Optional Comments

Never

For the treatment you provide, how often…

1

2

3

4

5

1

2

3

4

5

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Response

Often

Always

5.10 …do you provide information to clients
about healthy pregnancies and the effect of
maternal drug use on infants/children?

Sometimes

5.9 …do you provide counseling related to
substance abuse issues?

Rarely

5.4 …do you plan for a client’s discharge
throughout the treatment process (vs. doing
it right before discharge)?
5.5 ….do you provide printed materials,
pamphlets, or workbooks on issues related
to co-occurring substance abuse and mental
health problems?
5.6 …do you provide printed materials,
pamphlets, or workbooks on trauma,
domestic violence, or other women-specific
topics to your clients?
5.7 …do you provide counseling related to
PTSD or trauma such as sexual abuse and
domestic violence?
5.8 …do you provide counseling about healthy
relationships and how to avoid unhealthy
relationships?

Optional Comments

Never

For the treatment you provide, how often…

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

5.11 What is the 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:

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

5.12 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:
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5.13 On average, about how many women stay in each room while they are in your program?
____________ Women
DK
5.14

On average, about how many women share a bathroom while they are in your program?
____________ Women
DK

Now I’m going to ask you some questions about client access to their children during treatment….
5.15 On average, how much time do clients spend with their children who live with them in this program during the day?
____________ Hours
a. Do clients have different levels of access to older children vs. younger children?
No
Yes
DK
5.16 What type of access do clients have to their children who do not live with them in this program but for whom they have
custody (i.e., visitation, privacy, phone)?
a. Where do clients meet with their children who do not live with them in the program?

Section 6. Discharge Planning

Always

Often

Sometimes

Ra rely

Discharge Planning

Never

Now I’m going to ask you about discharge planning for the clients you have treated in this program

By the time women are discharged from your PPW program, about how often…
6.1 …have they been taught about women’s
self-help groups (like AA, NA, or other
groups)?
6.2

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

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

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

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Optional Comments

1

2

3

4

5

1

2

3

4

5

Always

Often

6.5 …have they received help reconnecting to
estranged family members or significant
others?

Sometimes

6.4 …have they received help connecting to
social support systems such as recreational
or religious groups?

Ra rely

Discharge Planning

Never

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Optional Comments

Section 7: Post-Treatment Housing Services
Now I’d like to talk about post-treatment and transitional housing services provided to your clients after completing this
program.
Response

Post-Treatment Housing Services

Optional Comments

7.1 About what percentage of clients have a
1
2
3
4
5
concrete and specific post-treatment housing
plan that will support recovery?
<5% 25% 50% 75% ≥95%
Upon completing PPW treatment, about what percentage of your clients actually go…
7.2 …into an institution (hospital, inpatient or
other residential program, or jail/prison)?

7.3 …into transitional housing?

7.4 …into a living situation where drugs or
alcohol are abused in the home?
7.5 …into a potentially abusive domestic
situation?

1

2

3

4

5

<5% 25% 50% 75% ≥95%
1

2

3

4

5

<5% 25% 50% 75% ≥95%
1

2

3

4

5

<5% 25% 50% 75% ≥95%
1

2

3

4

5

<5% 25% 50% 75% ≥95%

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Section 8. Recovery Support/Continuing Care Services
Now I would like to ask you about any recovery support/ continuing care services available to the clients in your PPW
program.
8.1 Do you know about the recovery support/continuing care services offered to clients in this program once they have
graduated?
No→Go To Section 9
Yes
8.2 Does this program offer recovery support / continuing care services to clients who graduate?
No→Go To Section 9
Yes
Dk→Go To Section 9
8.3 Is continuing care mandatory for all clients who do not go to another treatment program upon discharge?
No
Yes
DK
8.4 What determines the duration, frequency, and content of continuing care?

8.5 What outreach practices does this program use for following up with clients who do not show up for continuing care?
Are there official outreach policies?

8.6 Do you or anyone in the program provide transportation for continuing care?
Yes, Respondent
Yes, Someone else in Program
No→Skip Next Item
DK
8.7 Do PPW counselors meet clients off-site for continuing care?
No→Go To Section 9
Yes
DK→Go To Section 9
8.8 On average, about how much time do you or other counselors spend each month meeting clients offsite for continuing
care?
________ Days
DK
8.9 How do your responsibilities change during continuing care? [Probe For Counseling, Case Management, Etc.]

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Section 9. Patient Satisfaction
Now, I would like to learn about things clients in your PPW program complain about most often and what they say they like
the best about the PPW program.
9.1 What is the most common complaint that clients have about this program? [Check All That Appy. Circle Most Common
If More Than One Check. Responses Can Be Used As Probes.]
Living conditions in the PPW program
Feelings of safety while in the PPW program
Other clients
PPW staff
Quality of treatment and types of services provided by the PPW program (i.e., wanting more services or help)
Program rules, restrictions, requirements
Don’t want to be in treatment, coerced into seeking treatment
Access to their children while they are in the program (the visiting hours, phone calls, etc.)
Other, specify
9.2 What do clients say they like most about this program? [Check All That Appy. Circle Most Common If More Than One
Check. Responses Can Be Used As Probes.]
Living conditions in the PPW program (food, physical accommodations)
Feelings of safety while in the PPW program
Other clients
PPW staff
Quality of treatment and types of services provided by the PPW program
Access to their children while they are in the program (the visiting hours, phone calls, etc.)
Other, specify
9.3 Do pregnant women differ from non-pregnant women in their complaints?
No
Yes→Describe.
DK
9.4 Do pregnant women differ from non-pregnant women in the things they say they like best about the PPW program?
No
Yes→Describe.
DK
Section 10.

Program Challenges/Strengths

Now I would like to discuss potential challenges faced by your program in delivering services to women and their children.
10.1 What types of women is the PPW program unable to serve? [Probe: This could be clients with particular health
issues, psychiatric issues, non-English speaking clients, etc.]

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10.2 What are barriers for women entering the PPW program (e.g., are there problems that prevent women who want to
enter the program from actually entering the program such as finding someone to care for their children while they are
in treatment)?

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

10.4 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?

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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?

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
…White
DK/Refused
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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
…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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