Institute of Behavioral Research

Community Forms: Women & Children Residential Treatment

The Women and Children Forms include a comprehensive set of 18 intake, during-treatment, and follow-up data collection instruments for assessing functioning and services in residential settings. The set includes 12 forms adapted specifically for women, and 6 forms for use with children. Issues related to drug use during pregnancy, child custody, and parenting strategies are addressed.

(Listed in sequence in which forms occur during treatment; times indicate typical length
to administer.)

The Urinalysis Report at Intake records presence or absence of nine commonly used
illegal drugs.

The Intake is administered by a counselor in a face-to face interview. It includes sections on sociodemographic background, family and peer relations, acculturation, health and psychological status, criminal involvement, in-depth drug use history, and an AIDS-risk assessment. [90 minutes]

The Self-Rating at Intake is completed by the client immediately prior to the Intake Form, after the client has been admitted to the program. It includes short scales for psychological adjustment (i.e., self-esteem, depression, anxiety, and decision-making), social functioning (i.e., childhood problems, hostility, risk-taking, and social conformity), and motivation (drug problems, desire for help, treatment readiness, and external pressures). It takes approximately 10 minutes.

Counseling Session Records

The Counseling Session Record — Individual (Counselor) describes the length and type of session as well as the issues addressed. [5 minutes]

The Counseling Session Record — Group (Counselor) describes the length and type of session as well as the issues addressed. [5 minutes]

The During-Treatment Status is completed by the client and re-assesses (for the previous 3-month period) family and peer relationships. Questions are a subset of the Intake Form. [10-15 minutes]

The Evaluation of Self and Treatment (for the previous 3 months) records client ratings of the counselor and the program in general. It also contains scales assessing psychological adjustment, social functioning, and motivation. [10 minutes]

The Counselor Rating of Client is completed by the counselor for the purpose of describing client functioning and therapeutic strategies used in the preceding 3 months. [5 minutes]

Services Tracking Records

The Services Tracking Record (Monthly) serves as the overall monitoring record of client services and transactions, and is completed each month by agency staff. It contains information concerning counseling session attendance, medications prescribed, urinalyses results, and ancillary services provided. [Time to complete this form varies, depending on agency record-keeping systems.]

The Treatment Phase Progress Record records the dates and pertinent information needed to document the client’s movement through the various phases of treatment. [updated regularly throughout treatment – 2 minutes]

The Discharge Report documents dates and reasons for leaving treatment. [5 minutes]

The Follow-up Interview is administered by a trained interviewer in a face-to-face session held at a designated time after discharge from treatment. It includes questions that are similar to the Intake Form, but also addresses functioning and outcome measures based on the posttreatment period. [90 minutes]

 List of Child Forms

(Listed in sequence in which forms occur during treatment; times indicate typical length
to administer.)

The Child Intake is administered by a counselor and completed by the mother in a face-to face interview. Mothers report on sociodemographic background, custody status, CPS involvement, health and psychological status, criminal involvement, and childcare/educational status for each child in treatment. [20 minutes]

Counseling Session Record

The Counseling Session Record — Child (Counselor) describes the length and type of session as well as the issues addressed. [5 minutes]

The Child Services Tracking Record (Monthly) serves as the overall monitoring record of child services and transactions, and is completed each month by agency staff. It contains information concerning counseling session attendance, medications prescribed, and ancillary services provided. [Time to complete this form varies, depending on agency record-keeping systems]

The Parental Discipline is completed by the mother and records the frequency and type of discipline used during the preceding 30 days. [5 minutes]

The Child Discharge Report documents dates and reasons for leaving treatment.
[5 minutes]

The Child Follow-up Interview is administered by a trained interviewer and completed by the mother in a face-to-face session at a designated time after discharge from treatment. It includes questions that are similar to the Child Intake Form, but also addresses outcome measures based on the posttreatment period. [20 minutes]

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