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www.ibr.tcu.edu/
pubs/datacoll/
wcforms.html
Questions
and Additional
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ibr@tcu.edu
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Webmaster
Updated:
28-Feb-2008
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. For technical questions, contact Dr. Danica Knight at d.knight@tcu.edu.
Latest Forms Version: December 1998
List of Parent
Forms and Child
Forms
TCU Project using these forms
For Additional Information and
References
Recommended Citation for TCU Women and
Children Residential Forms
Parent Forms
(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. 
(PDF; 5KB / 1 page)
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)
(PDF; 138KB / 40 pages)
(PDF; Answer Cards)
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. (PDF; 16KB / 6 pages) (Item-Scoring Guide)
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) (PDF; 17KB / 5 pages)
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) (PDF; 19KB / 7 pages)
(Item-Scoring Guide)
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) (PDF; 8KB / 2 pages)
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) (PDF; 15KB / 5 pages)
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) (PDF; 104KB / 27 pages and 5 answer cards)
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) (PDF; 44KB / 11 pages; Answer Cards)
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.) (PDF; 11KB / 2 pages)
The Parental Discipline is
completed by the mother and records the frequency and type of discipline used during the
preceding 30 days. (5 minutes). (PDF; 5KB / 1 page)
The Child Discharge Report documents dates and reasons for leaving treatment. (5 minutes) (PDF; 9KB / 3 pages)
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) (PDF; 38KB / 9 pages, with 1 answer card)
For
Additional Information and References
First Choice Project Publications
Recommended
Citation for TCU Women and Children Residential Forms
Simpson, D. D., & Knight, D. K. (1998). TCU data collection forms for women
and children residential treatment. Fort Worth: Texas Christian University, Institute
of Behavioral Research. [On-line]. Available: www.ibr.tcu.edu.
Forms Section
Contents
Permissions and Obtaining Forms
CJ Treatment Forms
TCU ADC Forms
Correctional Residential Forms
Psychometric Information and Assessment Workshops
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