Form Biannual Form Biannual Form Biannual Form

OMB # 0930- XXXX
Expiration Date: xx/xx/xxxx

PCAP Client Module

Biannual Documentation of Client Progress
Agency Name: _______________________

Site Name: __________________________

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

A. Documentation month (Based on enrollment date):

6

B. 6-month period covered by this form:

12

18

24

30

36

Start date: __ __ / __ __ / __ __ __ __
End date: __ __ / __ __ / __ __ __ __

SECTION 1. ALCOHOL/DRUG TREATMENT
Document client involvement with any and all alcohol/drug treatment during this 6-month period. Be sure to note
outcome of any previously “in progress” treatment from last 6-month report.
A.
Yes,
Completed
1

No
0

1.

Inpatient (30 day, or less than 30 day)

2.

Inpatient (more than 30 day)
If No, skip to Question 3.
a.

Length of Program:

__ __ __ days

DK = -7

b.

Time she spent IN Program:

__ __ __ days

DK = -7

3.

Outpatient

4.

Methadone dosing

5.

Yes, In
Progress
2

Yes, But
Dropped
3

Don’t
Know
-7

B.
Name of Treatment Facility/Agency

Alcohol/drug support group
If No, skip to Question 6.
a.

Type of group:

AA

NA/CA

both

other: _______________

6.

Individual counseling

7.

Detox

8.

Treatment program in jail or prison

9.

Other treatment, specify what
kind:______________________

10. Treatment was for:

Alcohol

Drugs

11. Treatment was:

Mandated

12. Was/were her child(ren) with her in treatment?

Both

N/A*

Don’t Know

Voluntary

N/A

Don’t Know

No

Yes

N/A

Don’t Know

13. Any alcohol/drug assessment for tx done?

No

Yes

Don’t Know

14. Did she have UA monitoring? (outside of treatment)

No

Yes

Don’t Know

Comments on ALCOHOL/DRUG TREATMENT:

11/25/2008
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Parent-Child Assistance Program (PCAP)
University of Washington

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 OMB control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 40 minutes per client per year,
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, including suggestions for reducing this burden, to
SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland,20857.

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

SECTION 2. ABSTINENCE FROM ALCOHOL & DRUGS
Complete at end of 6-month documentation period. As of the date this 6-month period ends:
15. Is client currently clean from drugs? (for at least one month)

Don’t Know
-7

No

Yes

If Yes or Don’t Know, skip to Question 17.

16. If using at end of 6-month period, what drugs does client use now? (check a response for each)
a. Cocaine
No or Don’t Know
Yes
b. Heroin
No or Don’t Know
Yes
c. Marijuana
No or Don’t Know
Yes
d. Crack
No or Don’t Know
Yes
e. Methamphetamine
No or Don’t Know
Yes
f. Other
No or Don’t Know
Yes
Specify other:________________________________________

17. How many months currently clean? (Total consecutive PCAP months, not just of last 6)

__ __ months

(Code 00 if used in last month of this 6-month period)

18.

Is client currently abstinent from alcohol? (for at least one month)

No

19.

How many months currently abstinent? (Total consecutive PCAP months, not just of last 6)
(Code 00 if drank in last month of this 6-month period)

__ __ months

Does client have a problem with alcohol?

No

20.

Yes

Yes

(i.e., alcoholic; answer even if client does not currently drink)

21. Since starting PCAP, what is the longest number of months in a row client
has been clean and sober with no relapses, even if currently using.
(Do not count cigarettes & methadone use. Do not count time when she was not enrolled in PCAP).

Never

1-2

3-5

6-11

12-17

18-23

24-29

30-35

all 36

Check only ONE.

Alcohol Assessment
During the past 30 days, on how many days did you drink one or more of an
alcoholic beverage?

________ days

How many drinks did you have on a typical day when you were drinking
alcohol in the past 30 days?

10 or more
9
8
7
6
5
4
3
2
1
0

How often did you have 4 or more drinks in one day in the past 30 days?

10 or more
9
8
7
6
5
4
3
2
1
0

Comments on ABSTINENCE FROM ALCOHOL & DRUGS:

11/25/2008
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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

SECTION 3. BIRTH CONTROL & PREGNANCY
As of the end of this 6-month period:
22. Is client using birth control regularly? (i.e., has a consistent birth control method)

No

Yes

Don’t Know

23. What kinds of birth control does she currently use? (Regular or not; check a response for each)
a. Depo Provera shots
b. Norplant
c. Tubal Ligation
d. IUD
e. Pills
f. Condoms
g. Morning after pill
h. Other method

No or Don’t Know

Yes

No or Don’t Know

Yes

No or Don’t Know

Yes

No or Don’t Know

Yes

No or Don’t Know

Yes

No or Don’t Know

Yes

No or Don’t Know

Yes

No or Don’t Know

Yes
Specify other method: __________________________________

24. If not using birth control currently, is there a particular reason why not? ______________________________
If using a method, skip this question

25.

Was client pregnant in last 6 months?

No

Yes, currently

Yes, but not now

Don’t Know

If No, Yes currently, or Don’t Know, skip to Question 26.

a. If pregnant in last 6 months but not now, what was the outcome of that pregnancy?
Gave birth to target child
Gave birth to another child*
Terminated (abortion)
Miscarried
Stillbirth*

Don’t Know

*If outcome was gave birth to another child or stillbirth, submit a Notification of Subsequent Birth Form.

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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

SECTION 4. CONNECTION TO OTHER SERVICES
SERVICES FOR HOUSEHOLD — What services has client’s household used in the past 6 months? Check appropriate
box for each service. If problems with service please note what kind of problems in comments area.
Yes,Working
Well
1

Yes,but
Problems
2

No, But
Needed
3

Np, Not
Needed
4

Don’t
Know
-7

26. Basic Needs (food banks/clothing/supplies)
27. Food Stamps
28. Medical Coupons
29. Emergency funds or emergency bill paying service
(utility vouchers/rent assistance, Salvation Army, etc.)

a. Specify type: ___________________________________
30. Public Health Nurse
31. Public Housing (section 8, low income, subsidized)
a. On waiting list?
No
Yes

Waiting list closed

32. Emergency housing (include shelters)
33. Transitional Housing
34. Child Protective Services (CPS) If No, skip to Question 34b.
a. IF YES, Who:

Target child

Other child(ren)

b. CPS report filed in last 6 months?

No

Target child+other child(ren)
Yes (if yes, describe in comments)

If No, skip to Question 35.

c. Report by:
d. Report on:
e. On behalf of:

Advocate

Other Person:______________________

Client

Other Person:______________________

Target child

Other child

Target child+others

Comments on SERVICES FOR HOUSEHOLD:

11/25/2008
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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

SERVICES FOR CLIENT during past 6 months

Date: __ __ / __ __ / __ __ __ __

Yes,Working
Well
1

Yes,but
Problems
2

No, But
Needed
3

Np, Not
Needed
4

Don’t
Know
-7

35. Healthcare Provider (doctor)
36. Other Health Service (eye doctor, PT, dentist;)
a. Specify Type: _________________________________
37. Family Planning Service
38. Mental Health Counseling, Individual
39. Mental Health Counseling, Group
a. Specify Type: _________________________________
40. Domestic Violence Service (shelter, group, etc.)z
a. Describe: _____________________________________
41. Any Legal Services, Civil (e.g., child custody, restraining order, etc.)
a. Describe: _____________________________________
42. Any Legal Services, Criminal
a. Describe: _____________________________________
43. SSI/Disability (applications, hearings, etc.)
a. Specify Type: __________________________________
44. Academic/Vocational Skills Training (applications, attending, tutoring)
a. Describe: _____________________________________
45. Personal/Social Skills Training
a. Describe: _____________________________________
46. Positive Recreation/Enrichment (exercise, library card, etc.)
a. Specify: ______________________________________
47. Other Service
a. Specify: ______________________________________
Comments on SERVICES FOR CLIENT:

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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __
Don’t
Know
-7

CUSTODY OF TARGET CHILD
48. Who has legal custody of target child at end of 6 months?
Client
Other family*
Adoptive family

Bio dad
The state
Tribal authority

Child deceased
Other*
*Other, who: _____________________________________

49. Who does target child live with at end of 6 months?
Client
Other family*
Adoptive family

Bio dad
State/foster family
Child deceased

Child deceased
Other*
*Other, who: _____________________________________

50. For how many months of the past 6 did the target child live with client?

__ months

(code 0 if none; if less than 1 month code 1)

51. For how many mos. of the past 6 did the target child live in state-paid foster or family care?

__ months

(code 0 if none; if less than 1 month code 1)
Comments on CUSTODY OF TARGET CHILD:

SERVICES FOR TARGET CHILD (TC) during past 6 months

Yes,Working
Well
1

Yes,but
Problems
2

No, But
Needed
3

Np, Not
Needed
4

Don’t
Know
-7

52. Healthcare Provider (doctor)
53. Other Health Services (eye doctor, PT, dentist)
a. Specify Type: ___________________________________
54. High Risk Clinic
55. FAS Clinic
56. Therapeutic Child Care Center
57. Daycare/Childcare
a. Where: ________________________________________
58. Mental Health Counseling for Target Child
a. If YES, problem: _________________________________
59. SSI/Disability
a. Describe: ______________________________________
60. Other Service for Target Child
a. If YES, what services? ____________________________
Comments on SERVICES FOR TARGET CHILD:

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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

Don’t

SERVICES FOR TARGET CHILD (TC) during past 6 months (continued)

Know
-7

61. Are target child’s well-child visits up-to-date?

No

Yes

62. Are target child’s immunizations up-to-date? If Yes, skip to Question 59.
a. If not fully immunized, why not: ________________________

No

Yes

Yes

Suspect So

63. Does TC have chronic medical condition or special healthcare needs?
a. Describe: ________________________________________

No

64. If target child was living with someone other than client, did advocate help or try
to help link foster parent/guardian to any direct services for the target child in the
past 6 months?
*Other, who: ____________________________________________

No

Yes

N/A

Comments on SERVICES FOR TARGET CHILD:

SERVICES FOR OTHERS during past 6 months - Only if PCAP advocacy played a role
Don’t Know

CLIENT’S OTHER CHILDREN:
65. Did client have any children (biological or not) living with her in past 6 months?

-7

No

Yes

Did you or any other PCAP advocate help connect any of the client’s children, biological or not, to any
of the following? Do not include target child.
66. Healthcare Services (doctor, dentist, immunizations)
a. Specify: ___________________________________________________

No

Yes

67. Public Schools/Educational (conferences, ed. counseling)
a. Specify: ___________________________________________________

No

Yes

68. Mental Health/Counseling
a. Specify: ___________________________________________________

No

Yes

69. Recreational/Cultural Activities
a. Specify: ___________________________________________________

No

Yes

70. Other Service for Child
a. Specify: ___________________________________________________

No

Yes

Comments on SERVICES FOR CLIENT'S OTHER CHILDREN:

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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

SERVICES FOR OTHERS during past 6 months - Only if PCAP advocacy played a role (continued)
Don’t Know
-7

CLIENT’S PARTNER(S):
71. Did client have a partner(s) during this past 6 months? (supportive or not)
a. Comments on partner(s): ____________________________________________

No

Yes

72. Alcohol/Drug Treatment (incl.assessment)
a. Type: _____________________________________________________

No

Yes

73. Domestic Violence Counseling/Service
a. Specify: ___________________________________________________

No

Yes

74. Employment/Job Training Assistance

No

Yes

75. Legal (includes P.O.’s, INS)
a. Specify: ___________________________________________________

No

Yes

76. Other Service for Partner (incl. medical or mental health)
a. Specify: ___________________________________________________

No

Yes

Did you or any other PCAP advocate help connect client’s partner(s) to any of the following?

Comments on SERVICES FOR CLIENT'S PARTNER(S):

CLIENT’S FAMILY: Did you or any other PCAP advocate help connect client’s family to any of the following?
77. Alcohol/Drug Treatment (incl.assessment) a. Type: _______________________

No

Yes

78. Domestic Violence Counseling/Service

No

Yes

79. Employment/Job Training Assistance

No

Yes

80. Other Service for Family Member

No

Yes

a. Specify: ___________________________________________________
Comments on SERVICES FOR OTHER CLIENT FAMILY:

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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

SECTION 5. FAMILY STABILITY & CLIENT ACTIVITY
LIVING SITUATION/HOUSING
81. In what housing situations has client lived during past 6 months?(check yes or no for each)

No
0

Yes
1

Don’t
Know
-7

a. Homeless (01)
b. Living in Shelters/Motels (02)
c. Living with Friends/Relatives (03)
d. Permanent Housing (04)
e. Transitional Housing (05)
f. Transitional Clean & Sober Housing (06)
g. Inpatient treatment (includes MH & alc/drg tx) (07)
h. Incarcerated (jail, prison, etc.) (08)
i. Other situation (09): ______________________________________________
82. What is her CURRENT housing situation? (Enter 2 digit number from above)

__ __

83. Who lives with client in her current housing situation at the END of this 6-month period?
Situations with no children

Situations with children

Lives alone
Lives with child/children, no other adults
Lives with husband, no children
Lives with husband & child/children
Lives with boyfriend/girlfriend (domestic partner, no children)
Lives with boyfriend/girlfriend & child/children
Lives with parents, grandparents, other family, no children
Lives with relatives & children
Lives with in-laws &/or their family, no children
Lives with in-laws &/or their family, plus child/children
Lives with non-related women/men (roommates), no children
Lives with non-related roommates & children
Some other situation: ________________________________________________________

84. During this 6-month period, was any housing PCAP contracted housing?
85. Has client moved in past 6 months? Code # of moves. (00=no moves; 66=too many moves to count)

No

Yes

__ __

Comments on LIVING SITUATION/HOUSING:

CLIENT’S BIOLOGICAL CHILDREN (INCLUDING TARGET CHILD)
Don’t
Know
-7

As of the date the 6-month period ends:
86. Location of client's biological children (including Target Child):
a. How many of client’s biological children live with client? (code # of children; 00=none)
b. How many of client’s biological children do NOT live with client?

__ __
__ __

Comments on BIOLOGICAL CHILDREN:

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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

SOURCES OF INCOME IN PAST 6 MONTHS

No
0

Yes
1

Don’t
Know
-7

87. What sources of income has client had in the past 6 months? (check yes or no for each)
a. Employment (hers) (01)
b. Odd jobs she does (02)
c. Parent/grandparent (03)
d. Other relative (04)
e. Husband/boyfriend (05)
f. Friends/acquaintances (06)
g. Welfare (07)
h. SSI/Disability (08)
i. Other government check (GAU, etc.) (09), specify: ______________________
j. Tribal funds (10)
k. Other (11), specify: ______________________________________________
l. Drug sales/prostitution (12)
m. Fraud/check-kiting (13)
n. Other illicit (14), specify:___________________________________________

__ __

88. What is her main source of income at end of 6-month period? (Enter 2 digit number from above)
89. Has client been employed during this 6-month period, even if currently not?
a. How long employed this 6 month period:
b. Type of employment

None

__ months

__ weeks

Full-time (F/T)

No

__ days

Yes

(Don’t Know = -7 / -7 / -7)

Part-time (P/T)

Irregular Work

Was employed, but don’t know what type of employment

c. Describe: ___________________________________________________________________
90. Client is currently employed?
(Currently=At end of 6 month period)

No

Yes, F/T

Yes, P/T

Yes, Irregular Work

Yes, employed, but don’t know what type of employment

a. Current job: _____________________________________________________
91. Does client currently receive welfare for herself or her children?(do not include food stamps)
a. Number of months client/family received welfare during last 6 months:

No

Yes

__ months

92. During the past 6 months, did client: (if no welfare past 6 months, code No)
a. STOP receiving welfare
Reason: ________________________________________________

No

b. START receiving welfare
Reason: ________________________________________________

No

Yes, because of work
Yes, other reason
Yes, because of work
Yes, other reason

Comments on SOURCES OF INCOME:

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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

OTHER EVENTS IN PAST 6 MONTHS
No
0

In the last 6 months, have any of the following events occurred?

Yes
1

Don’t
Know
-7

93. Client has taken parenting classes in the last 6 months? If No, skip to Question 93.
a. Class: ___________________________________________________________
b. Code # weeks attended (00=none)

__ __ weeks

c. Course completed?
94. Client has a chronic medical condition? (incl. chronic STD, Hepatitis)
a. Describe/Specify: __________________________________________________
95. Client has visited the Emergency Room (E.R.) for medical care for herself or a child?
Inappropriate use of the service. If No, skip to Question 95.

a. Code # of times

__ __ times

96. Client has visited the Emergency Room (E.R.) for medical care for herself or a child?
Appropriate use of the service. If No, skip to Question 96.

a. Code # of times

__ __ times

97. To help her maintain a clean and sober lifestyle, does client have in her life:

No

Yes

a. A supportive partner?
b. A supportive person (other than partner or advocate)?
c. A support system (social, church, 12-step sponsor)?
Specify support system:____________________________________________
98. During the past 6 months, has client been in what you would consider an abusive
relationship with her partner(s)? (If no partner, code No)
a. Describe: ________________________________________________________
99. Has client assaulted anyone in past 6 months? If No, skip to Question 100.
a. If so, who:

Child

Partner

Other:

_____________________

b. Situation: _________________________________________________________
Comments on OTHER EVENTS:

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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

Date: __ __ / __ __ / __ __ __ __

ARRESTS/JAIL
No
0

In the last 6 months, have any of the following events occurred?

Yes
1

Don’t
Know
-7

100. Was client arrested in past 6 months? If No, skip to Question 101.
a. Charges: _________________________________________________________

__ __ times

b. Number of times arrested
c. Charge(s) are:

New charge

Old warrant

Both

101. Was client jailed in past 6 months? If No, skip to Question 102.
a. Number of times jailed

__ __ times

b. For what? _________________________________________________________
c. Facility: _________________________________________________________
102. Was client in Home Detention at any time during past 6 months?
103. Was client in Prison at any time during past 6 months? If No, skip to Question 104.

___________________________________________________________
b. # of months (of 6):
__ mos
a. Facility:

104. Was client on Probation at any time during past 6 months?
105. Did advocate play a role in type of sentence imposed in past 6 months?
If No, skip to Question 106.

a. If yes, how so?

_____________________________________________________

Comments on ARRESTS/JAIL:

EDUCATION/TRAINING
In past 6 months, has client attended and/or completed:

No
0

Attemded
1

Completed
2

Don’t
Know
-7

106 GED classes
a. Where: ______________________________________________
107. Community college
a. Where: ______________________________________________
108. Four-year college
a. Where: ______________________________________________
109. Vocational training class
a. What/where: _________________________________________
110. Training through work/employment
a. What/where: _________________________________________
111. Other course/class
a. Specify: _____________________________________________
Comments on EDUCATION/TRAINING:

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Parent-Child Assistance Program (PCAP)

Client #: __ __ __ __ __ __

VALIDITY
112. Advocate is confident of accuracy of information presented in this report:

Date: __ __ / __ __ / __ __ __ __

Yes

Mostly

Not at all

Comments on validity: (if you code Mostly or Not at all, note why) ________________________________________________

Comments on client’s situation during this six months:

Advocate #: __ __ __

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Parent-Child Assistance Program (PCAP)