Form Instrument for Pro Instrument for Pro Instrument for Program Director

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ATTACHMENT I:

INSTRUMENT FOR PROGRAM DIRECTOR

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Site Visit Protocol-Program Director Interview

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Attachment I-1

Site Visit Protocol – Program Director Interview

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Program Director Interview*
2-8-10
[Words in capital letters 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:

______________________________________________

Program Director Name:

______________________________________________

Program Director Gender:

M

F

Program Director 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

1.3

Start Date

End Date

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

Are you responsible for any other programs/modalities in addition to PPW?
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?
______ %

1.5

Please tell me about your educational background and credentials including any licenses or certifications.

1.6

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

1.7

Facility Type

Duration (In Years)

Has program director provided direct clinical care?
No
Yes

Section 2:

Program Structure and Philosophy

This study focuses on women and their children who have received treatment in your PPW program since your grant started.
[Skip 2.1 If already have this information from the clinical director / supervisor.]
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?

2.2

Please describe how the organization is structured from an administrative standpoint. [Request organization chart.]

2.3

How many women and children does your PPW program currently serve?
______Women
______Children

2.4

How many women and children is your program capable of serving?
______Women
______Children
a. If program is not at capacity (2.4 – 2.3), why not?

2.5

What licensing/certifications for services does your agency currently hold?

2.6

May I have a copy of your mission statement?
[Interviewers to Fill In Later: Check all that apply based on review of PPW mission statement. PPW mission
statement addresses:]
Treatment for Women
Behavioral Health
Co-Occurring Disorders
Mission Statement not just for PPW Program
No Mission Statement Provided
No Mission Statement Exists

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Section 3:

Patient Admissions Patterns

Now I would like to talk with you about client admission to your PPW program since your grant started.
Referral Sources
3.1
Since your grant started, about what
percentage of the clients referred here have
you been unable to admit to your program?

1

2

Response
3
4

<5% 25% 50%
└→Skip Next Item

3.2
For what reason(s) has the program been
unable to admit clients? [Select all that apply.]

75%

Optional Comments
5
≥95%

Limited Beds
Client(S) Chose Not To Come
Reimbursement Issues
Stage Of Pregnancy
Other, Specify
NA – Admitted All Women

If more than one reason selected:
3.3
What is the one most common reason?
(Circle choice.)

About what percentage of the clients served by your PPW program…
3.4
…are referred for PPW treatment by the
child welfare system?
3.5
…are referred for PPW treatment by the
criminal justice system?
3.6
…are referred for PPW treatment by
other substance abuse programs?
3.7
…are referred for PPW treatment by
mental health programs?
3.8
…are referred for PPW treatment by
employer/EAP?
3.9
…are referred for PPW treatment by
Health services/HMO’s?
3.10

…are referred for treatment by Self?

3.11 …are referred for PPW treatment by
Family?
3.12 …are referred for PPW treatment by
Other, specify?
3.13 …live in the same community or within
25 miles of this PPW facility?
3.14 …have reunification with their child(ren)
as a primary goal of treatment?

1

2

3

4

5

<5% 25%
1
2

50%
3

75%
4

≥95%
5

<5% 25%
1
2

50%
3

75%
4

≥95%
5

<5% 25%
1
2

50%
3

75%
4

≥95%
5

<5% 25%
1
2

50%
3

75%
4

≥95%
5

<5% 25%
1
2

50%
3

75%
4

≥95%
5

<5% 25%
1
2

50%
3

75%
4

≥95%
5

<5% 25%
1
2

50%
3

75%
4

≥95%
5

<5% 25%
1
2

50%
3

75%
4

≥95%
5

<5% 25%
1
2

50%
3

75%
4

≥95%
5

<5% 25%
1
2

50%
3

75%
4

≥95%
5

<5% 25%

50%

75%

≥95%

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Section 4. General Program Environmental Features
Now I’m going to ask you about your 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.
Response

Agree

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

4.5
The race/ethnicity of staff reflects the
cultural diversity of the clients.

1

2

3

4

5

4.6
Program includes positive cultural
experiences and materials.

1

2

3

4

5

4.7
The PPW visiting hours are sufficient
(in your clinical opinion).

1

2

3

4

5

4.8
In general, PPW clients feel that PPW
visiting hours are sufficient.

1

2

3

4

5

4.1
The PPW program is located in a safe
neighborhood in terms of crime and drug use.
4.2
The PPW program environment
/setting is safe and secure. That is, entry to
program is protected, and security procedures
in place.
4.3
Some common area(s) of the facility
are accessible ONLY to women.
4.4

Smoking areas are supervised.

Strongly
Agree

Undecided

1

Strongly
Disagree

Disagree

General Program Environment

Optional Comments

If 4 or 5, describe.

Section 5. Children’s Services
Now I’m going to ask you about any services your PPW program might provide for the children of women in your PPW
program.

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Service

Optional Comments

Response
Limits:
Girl’s age: ____________
Boy’s age: ____________
# per woman: _________
Stay only a few days at a
time
Very rare for child to stay
Other, Specify:

5.1
Are there limits to the services your
PPW program provides to clients’ children
living with them in your program? (Such as the
child’s age, the number of children, and/or how
long the child can stay with the mother?)

While the mother is still in the PPW program, about what percentage of the children who are in her custody
(both those who live and do not live with them in the program)…
1

5.2
Are screened or assessed for behavioral
health and developmental challenges?

2

3

4

5

<5% 25% 50% 75% ≥95%
└→Skip Next Item
Onsite
Offsite
Both
Other, Specify:

a. If >1 above, Does this take place onsite,
offsite, or both?

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

Agree

5.3
There is comfortable play space for
children visiting the program.

2

3

4

5

5.4
There are areas for mothers and
visiting children to interact naturally.

1

2

3

4

5

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Strongly
Agree

Undecided

1

Strongly
Disagree

Disagree

General Program Environment

Optional Comments

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Section 6.

Staff Competencies and Training

Now I’m going to ask you about the CLINICAL staff who work here. This includes counselors and anyone who provides
direct clinical services to clients.
6.1

Does the PPW program have a policy regarding matching clients and counselors by gender?
No
Yes→Specify.

6.2

Is priority placed on hiring PPW staff that are in recovery?
No
Yes

Currently, about how many (A, B, C)...
6.3

(A)
#
Counselors

(B)
#
CMs

C = Other
Residential Assistants,
Treatment Attendants,
Health/ House Managers, Etc.

…work in the PPW program?

6.4
… have an addiction counseling
certification? (This can be a basic or
advanced certification)
6.5
…have a mental health treatment
license?
6.6

(C)
# Other

…are in recovery themselves?

NA

NA

NA

NA

NA

NA

About what percentage of CLINICAL staff who work with PPW clients have…
6.7
…special training in co-occurring
disorders?
6.8

…special training in women’s issues?

6.9
…special training in trauma and/or
PTSD?
6.10
…licensure or certification in child
and/or family issues?
6.11
…special training in culturally-relevant
treatment issues?
6.12
…received special training in your PPW
program’s treatment model philosophy? (i.e.,
training in structured treatment
protocols/manuals

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%
1
2
3
4
5
<5% 25% 50% 75% ≥95%
1

2

3

4

5

<5% 25% 50% 75% ≥95%

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Please describe training:

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Now I’m going to ask you about your meetings with the CLINICAL staff who work for your PPW program and any training
you provide for your CLINICAL staff.
6.13
About how often do you hold formal staffings, case conferences, or treatment planning meetings, where you review
clients’ progress?
Daily
Weekly
Monthly
It Varies
Don’t/ Only Informally
6.14
On average, about how long are these case review conferences or meetings? (Please estimate for an individual client,
including general meeting time.)
_____ Min Total
From ____ To ____ Min Per Client
Typically ____ Min Per Client
DK
6.15
Does the PPW program provide continuing education or in-service training or require other specific training for
clinical staff?
No→Go To 6.19
Yes→Describe.
Other, Specify:
6.16

About how often is training provided?
[Choose All That Apply]
Annually or more often
Less than annually
When new staff are hired
Other, Specify:

6.17

(Who usually provides this training)?
[Choose All That Apply]
PPW staff
Non-PPW staff from same facility
Outside consultants
Programs offered elsewhere
eLearning (on computer)
Other, Specify:

6.18

About how much time each year does each clinical staff spend getting training related to women and their recovery?
From ____ To ___ Hours / Year
Mean = ___ Hrs Per Staff/ Year

6.19

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

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Never

Rarely

Sometimes

Often

Always

(Again, please think only about those CLINICAL staff that provides services to PPW clients.)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

6.23
…impact of cultural issues on treating
women?

1

2

3

4

5

6.24
…women’s sexuality, sexual orientation,
and related concerns?

1

2

3

4

5

6.25
…the effect on women of trading sex for
drugs or money to buy drugs?

1

2

3

4

5

6.26
…the role of trauma and issues of retraumatizing women?

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

6.29
…community supports available for
women?

1

2

3

4

5

6.30
…role of parenting or caretaking in
recovery?

1

2

3

4

5

To what extent does the training provided,
sponsored, or endorsed by the PPW program
include…
6.20
…current theory of women’s development
from childhood through adulthood?
6.21
…unique characteristics of women with
mental health and substance abuse issues?
(Including ways in which women develop
behavioral and health problems that are distinct
from men.)
6.22
….role of co-occurring other mental
health problems in women’s recovery (such as
depression, anxiety disorders, PTSD, eating
disorders)?

6.27

…sexual abuse?

6.28

…family violence?

6.31

Optional Comments

What supports are in place to enhance staff morale and provide care for them as caregivers?

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Section 7:

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?

7.1
Financial
matters

7.2
Keeping
the PPW
program at full
capacity (i.e.,
beds full)

7.3
Administr
ation or
management of
the program

7.4
Finding
and keeping
qualified staff

1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

Very
Much

If A=2-5:
Much

Somewhat

Little

Program
Challenge Area

Not at all

(A)
Rating

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

5

5

5

5

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If A = 2-5:

Low Staff Pay
Increased Costs
Budget Cuts
Limited Reimbursement
Other, Specify:

Ongoing
Resolved
(Specify)

Client Flow
Clients View Program As Restrictive
Other, Specify:

Ongoing
Resolved
(Specify)

Regulations Imposed By State, Etc.
Funding
Modernizing Tx Philosophy/ Structure
Other, Specify:

Ongoing
Resolved
(Specify)

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

Ongoing
Resolved
(Specify)

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7.5

Facilities

7.6
Meeting
clients’ needs
for services

7.7
Visitation
with children
(who are not in
treatment with
mother)

7.8
Providing
services to
children within
PPW program

1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

Very
Much

If A=2-5:
Much

Somewhat

Little

Program
Challenge Area

Not at all

(A)
Rating

(B) Description/Source of Challenge
[Don’t Read Categories]
Old Or Run-Down
Insufficient Space
Access To Community /Public
Transport
Neighborhood Iffy (Drugs, Crime)
Other, Specify:

5

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:

5

5

5

Ongoing
Resolved
(Specify)

Ongoing
Resolved
(Specify)

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)

NA

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If A = 2-5:

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7.9
Having
prenatal or
perinatal
services
available
ONSITE

7.10
Client
satisfaction

1

2

3

4

Very
Much

If A=2-5:
Much

Somewhat

Little

Program
Challenge Area

Not at all

(A)
Rating

(B) Description/Source of Challenge
[Don’t Read Categories]
Expensive W/ Inadequate
Reimbursement
Need Is Variable So Hard To Keep
Resources/Linkages Fresh
Other, Specify:

5

If A = 2-5:

Ongoing
Resolved
(Specify)

NA

1

2

3

4

5

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)

7.11
What services are not currently provided to PPW clients and/or their children/family members that you think would
enhance their treatment?

7.12

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?

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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?

e.

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

Section 8:

Recovery Support/Continuing Care Services

Now I would like to ask you about the recovery support/continuing care services that are available to clients in your PPW
program.
8.1

About what percentage of clients go to another program after discharge from your PPW program?
1
<5%

2

3

25% 50%

4
75%

5
≥95%

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8.2

Since your PPW program started, have clients received continuing care from your program following treatment?
No→Go To 8.3
Yes

8.3

If Yes above, Is it provided onsite, offsite, or both? [Skip Next Item]
Onsite
Offsite
Both
Other, Specify:

8.4
If No To 8.2, About what percentage of clients in your program have confirmed appointments prior to discharge with
treatment providers who will be providing continuing care (this includes discharge to another program? [Skip To Section
9]
1
2
3
4
5
<5%

25% 50%

75%

≥95%

Continuing Care Services

Response

Optional Comments

During recovery support/continuing care, about what percentage of your clients receive…
8.5

…counseling?

8.6

…alumni groups and/or activities?

8.7
…resource coordination, advocacy,
and/or case management?
8.8
…educational or vocational support
services?
8.9
…childcare when a client comes to the
facility for continuing care services?
8.10
…continued services for a client’s
children if they received them while she was
in your PPW program?

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%
1
2
3
4
5
<5% 25% 50% 75% ≥95%
1

2

3

4

5

NA

<5% 25% 50% 75% ≥95%

8.11
On average, for about how many months after PPW treatment completion do clients actually receive recovery
support/continuing care services from your PPW program?
_______ Months
DK

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Section 9: Comprehensiveness of Services for Women, Children, and Families
Comprehensive Services for Women
For each service listed below, list the % of pregnant or postpartum women served by your grant who have
received (or are currently receiving) each service while in your program, and place a  , C, or R in the
appropriate box(es). For all services that are contracted or referred out, please list the name of the outside
provider along with their phone number and email.
Services for Women

Intake Screening Assessments
Physical examination
Medical History and
Diagnosing
Allergies & adverse drug
reactions
STDs
HIV/AIDS
Hepatitis
TB
Gynecological/pelvic
examination
Dental examination
Speech and hearing
Nutrition
Vision
Mental health
Substance abuse
Emotional abuse trauma
Sexual abuse trauma
Physical abuse trauma
Employment history
Education level
Language proficiency/literacy
Housing needs
Legal needs
Child care responsibility and
needs
Criminal justice involvement
Eligibility for benefits
Other (specify)

% Clients
Receiving
Service

Provided
Onsite
()

Contracted /
Referred Out
(C or R)

Services - Medical
Detoxification
15

Outside Provider Information
(List name, Phone.#, and email
information for Provider)

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Services for Women

Prenatal/postpartum care
Laboratory testing
Routine urinalysis
Medical treatment for medical
diagnosis
Treatment of Hepatitis,
HIV/AIDS, other STDS
Family planning
Drug testing
Mammograms
Pap smear
Clinical breast exam
Pharmacotherapy
Other (specify)

% Clients
Receiving
Service

Provided
Onsite
()

Services – Mental Health
Couple/family therapy
Individual substance abuse
counseling
Group substance abuse
counseling
HIV/AIDS counseling
Hepatitis and STDS (not
HIV/AIDS) counseling
Trauma/survivors group
Mental Health Treatment
Mother-Child Parenting
/Bonding Classes
Mother/Child Counseling
/Classes
Individual Psychiatric Therapy
(based on psychiatric
diagnosis)
Group Psychiatric Therapy
(based on psychiatric
diagnosis)
Sexuality group (attitudes,
etc.)
Peer counseling
Art therapy
Anger group
Child Welfare reunification
services
Other (specify)

-16-

Contracted /
Referred Out
(C or R)

Outside Provider Information
(List name, Phone.#, and email
information for Provider)

I-19

Services for Women
% Clients
Receiving
Service

Provided
Onsite
()

Services - Health Education
Substance abuse education and
treatment
Health education about
HIV/AIDS
Health education about
Hepatitis and other STDS
Health education about
psychiatric diagnoses
Health counseling about
managing chronic disease
Nutrition education
Smoking cessation
Diet and exercise
Other (specify)
Services - Life Skills
Parenting skills training
Educational/GED tutoring
/assistance
Employment readiness
Employment training
Employment referral
/placement
Financial management training
Post-residential treatment
continuing care
Relapse prevention
Stress management
Coping skills
Assertiveness training
Self-defense
Other (specify)
Services - Other
Discharge planning
Linkage with socio-economic
support at State and Federal
levels (if eligible)
Transportation
Permanent housing
arrangements
Child care

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Contracted /
Referred Out
(C or R)

Outside Provider Information
(List name, Phone.#, and email
information for Provider)

I-20

Services for Women
% Clients
Receiving
Service

Provided
Onsite
()

Case management services
Recreational activity (field
trips, movies, team sports,
cultural, experiences, picnics)
Spiritual Activity
(meditational activities,
attendance at services,
watching video tapes, listening
to tapes, etc.)
Other (specify)

-18-

Contracted /
Referred Out
(C or R)

Outside Provider Information
(List name, Phone.#, and email
information for Provider)

I-21

Comprehensive Services for Children
For each service listed below, list the % of children served by your grant who have received (or are
currently receiving) each service while in your program, and place a  , C, or R in the appropriate box(es).
For all services that are contracted or referred out, please list the name of the outside provider along with
their phone number and email.
Services for Children
% Children
Receiving
Service

Provided
Onsite
()

Intake Screening Assessment
Physical examination
Medical History and
Diagnosing
Dental examination
Allergies and adverse drug
reactions
Speech and hearing
Vision screening
Nutrition
Developmental assessment
Mental Status Exam for
Children
Mental health
Substance abuse
Physical abuse trauma
Emotional abuse trauma
Sexual abuse trauma
Educational level
Eligibility for benefits
Other (specify)
Services - Medical
Medical treatment for medical
diagnosis
Laboratory testing
Immunizations
Other (specify)
Services – Mental Health
Individual counseling relating
to substance abuse
Individual psychiatric therapy
based on psychiatric diagnosis
Group therapy based on
psychiatric diagnosis
19

Contracted /
Referred
Out
(C or R)

Outside Provider Information
(List name, Phone.#, and email
information for Provider)

I-22

Services for Children
% Children
Receiving
Service

Provided
Onsite
()

Art therapy
Play therapy
Individual nurturing
Mother/father/child
counseling classes
Mother-child parenting/
bonding classes
Father-child parenting/
bonding classes
Trauma-related counseling
Group counseling for children
of substance abuse
Ala Tot
Ala Teen
Recreational therapy
HIV/AIDS counseling
Other (specify)
Services - Life Skills
Substance abuse prevention
Special/remedial education
(for learning disabled)
Physical therapy
Speech therapy
Occupational therapy
Coping skills
Self-esteem
Other (specify)
Services - Other
After care plan
Linkage with socio-economic
support at State and Federal
levels (if eligible)
Recreational activity (field
trips, movies, team sports,
cultural experiences, picnics)
Spiritual activity (meditation,
faith-based services, video
/audio tape/dvd, etc.)
Other (specify)

-20-

Contracted /
Referred
Out
(C or R)

Outside Provider Information
(List name, Phone.#, and email
information for Provider)

I-23

TI #__________
Comprehensive Services for Families
For each service listed below, list the % of clients served by your grant who have received (or are currently receiving) each service while in
your program, and identify if the clients are Fathers, Partners/Spouse, and/or Extended Family Members by placing a  in the appropriate
box(es). Additionally, for each service listed below identify if service was provided Onsite, Contracted, or Referred Out to another provider by
placing a  , C, or R in the appropriate box(es). For all services that are contracted or referred out, please list the name of the outside provider
along with their phone number and email.
Services For Families
% Clients
Receiving
Service

Outreach and Engagement
Phone calls to invite to program
Individual meetings
Home visit
Recreation activity (e.g., family
outing, celebration)
Transportation assistance to attend
program activity
Incentive for father/s and family
member/s to participate (e.g., gifts,
raffles)
Mailed program information to
invite to program
Male-oriented activities to engage
fathers/family members
Telephone support
Other (specify)
Services – Education and Mental Health
Family or couple counseling
Individual mental health treatment
Addiction treatment
Alcohol and drug education
Education on co-occuring

Fathers
()

Partners/
Spouses
()

Extended
Family
Members
()

21

Provided
Onsite
()

Contracted/
Referred
Out
(C or R)

Outside Provider Information
(List name, Phone.#, and email
information for Provider)

I-24

Services For Families

disorders
Psycho-educational support group
Support groups for coping with life
experiences
Parenting classes
Family strengthening and
preparation for safe reunification
or re-connection - information and
counseling
Nurturing, bonding for father/s and
family member/s to strengthen
attachment and relationships to
child/ren – information and
counseling
Domestic violence information and
counseling for victims
Domestic violence information and
counseling for perpetrators
Other (specify)

% Clients
Receiving
Service

Fathers
()

Partners/
Spouses
()

Extended
Family
Members
()

Services – Life Skills
Employment services
Education services
Education about social services
and benefits (TANF, food stamps,
health insurance, medical services,
food banks)
Education about services to ease
family members’ childcare burden
(respite, child care, after-school
program, early intervention, mental
health, summer camps)
Housing assistance
22

Provided
Onsite
()

Contracted/
Referred
Out
(C or R)

Outside Provider Information
(List name, Phone.#, and email
information for Provider)

I-25

Services For Families

Life-skills training (time
management, conflict resolution,
budgeting, stress management)
Assistance navigating systems
(e.g., child welfare/CPS, criminal
justice, mental health)
Assistance accessing services and
other entitlements (welfare, WIC,
TANF, SSI, DVR, etc.)
Community reintegration for
formerly incarcerated
fathers/family members
Connection to spiritual and faith
activities and support
Connection to culturally-specific
community supports and activities
Medical services
Assistance in accessing medical
treatment
Other (specify)

% Clients
Receiving
Service

Fathers
()

Partners/
Spouses
()

Extended
Family
Members
()

Services - Other
Advocacy
Childcare for families attending
program activities
Clothing donations
Other (specify)

23

Provided
Onsite
()

Contracted/
Referred
Out
(C or R)

Outside Provider Information
(List name, Phone.#, and email
information for Provider)

I-26

Section 10:

Respondent Demographic Information

Before we finish, I would like to ask you a few questions about your demographic characteristics.
10.1

Do you consider yourself to be Hispanic or Latino/a?
Yes
No
DK/Refused

10.2
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
10.3

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.
__________________________________________________________________________________________

24