| Date:______________________________ |
Rater(s):__________________________ |
| Program Name:______________________ |
| Address:___________________________ |
| Contact Person:_____________________ |
Title:______________________________ |
| Phone:______________________________ |
Fax:________________________________ |
| E-mail:_____________________________ |
| ____ Chart review |
____ Agency brochure review |
| ____ Team meeting observation |
____ Supervision observation |
| ____ Group or counseling session observation |
| ____ Interview with program director/coordinator |
| ____ Interview with clinicians |
____ Interview with clients |
| ____ Interview with rehabilitation service providers (Specify:_________________) |
| ____ Interview with ______________________ |
| ____ Interview with ______________________ |
| Number of DD clinicians: ______ |
Number of active clients with DD: ______ |
| Number of clients with DD served in preceding year: __________________ |
| Date program was started: _____________________________ |
