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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Monitoring Client Outcomes

Client Outcomes—Quarterly Report Form

Client ID: _____________________ Reported by: _______________________

Date: _________________________ Quarter: ___________________________

Indicate the client's status during the past 3 months. Check all that apply:

In the past 3 months, how many weeks has the client:

What has been the client's stage of substance abuse treatment during the past 3 months? Circle one.

What is the client’s current living arrangement? Circle one.

1. Psychiatric hospital
2. Substance use hospitalization
3. General hospital psychiatric ward
4. Nursing home or IC-MH
5. Family care home
6. Lives with relatives (heavily dependent for personal care)
7. Group home 8. Boarding house
8. Lives with relatives (but is largely independent)
9. Supervised apartment program
10. Independent living
11. Other (specify)
12. Emergency shelter
13. Homeless

What is the client’s current educational status? Circle one.

1. No educational participation
2. Avocational/educational involvement
3. Pre-educational explorations
4. Working on GED
5. Working on English as second language
6. Basic educational skills 7. Attending vocational school or apprenticeship, vocational program (CNA training) or attending high school
7. Attending college—1-6 hours
8. Attending college —7 or more hours
9. Other (specify)

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