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| * Supervising Officer/Case Manager Name: | | |
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Directions: In the next section you will rate the client’s general progress in the area of various contacts over the past 30 days. |
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| 1. Over the last 30 days, what was the average length (in minutes) of your face-to-face contact(s) with the client: ____ minutes | | |
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2. Indicate the number of times you initiated contact with the client during the last 30 days:
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3. Indicate the number of times the client contacted you during the last 30 days:
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4. Please indicate the number of times in the last 30 days that:
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5. During the last 30 days…
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Directions: In the next several sections you will rate the client’s progress over the past 30 days in specific content areas. Progress refers to how well the client is addressing the areas that affect success on supervision. |
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1. Select the number representing your view of the client’s overall progress on supervision during the past 30 days:
1= Negative; 5=About the Same; 10=Positive
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EMPLOYMENT PROGRESS DURING THE PAST 30 DAYS |
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2. What is the client’s current employment status? (select one) |
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| If employed part-time, specify the average number of hours per week | | |
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3. In the past 30 days has the client: |
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4. Select the number representing your view of the client’s employment progress during the past 30 days:
1= Negative; 5=About the Same; 10=Positive
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5. On a scale of 1 to 5, indicate the extent to which the client demonstrated the following characteristics:
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ATTITUDE TOWARD SUPERVISING OFFICER/CASE MANAGER DURING THE PAST 30 DAYS |
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6. Select the number representing your view of the client’s progress in improving attitudes toward his/her supervising officer during the past 30 days:
1= Negative; 5=About the Same; 10=Positive
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7. On a scale of 1 to 5, indicate the degree to which you agree with the following statements:
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7. On a scale of 1 to 5, indicate the degree to which you agree with the following statements:
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SOCIAL SUPPORT DURING THE PAST 30 DAYS |
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1. How would you best describe the client’s current support networks: |
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2. In the past 30 days has the client experienced a problem with at least one person he/she depends on? |
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3. Select the number representing your view of the client’s progress on his/her social networks during the past 30 days:
1= Negative; 5=About the Same; 10=Positive
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4. On a scale of 1 to 5, indicate the degree to which you agree with the following statements:
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HOUSING PROGRESS DURING THE PAST 30 DAYS |
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1. How would you best describe the client’s housing stability over the past 30 days? |
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If client has moved within the past 30 days, select the option best representing his/her current housing status: |
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| Drug treatment facility (how many days______) | | |
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| Other healthcare residential facility or institution (how many days______) | | |
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| 2. Note any other major changes in housing: | | |
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3. Does the client live in an area where a number of other individuals on community supervision live? |
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4. Select the number representing your view of the client’s progress on his/her housing during the past 30 days:
1=Negative; 5=About the Same; 10=Positive
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SUPERVISION PLAN DURING THE PAST 30 DAYS |
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1. Select the number representing your view of the client’s progress on meeting any educational requirements during the past 30 days.
1= Negative; 5=About the Same; 10=Positive
Select N/A (not applicable) if the client is not required to participate in educational programming.
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2. Select the number representing your view of the client’s progress in dealing with and maintaining separation from any peers involved in criminal behavior or on probation/parole during the past 30 days.
1= Negative; 5=About the Same; 10=Positive
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3. Select the number representing your view of the client’s progress on participation in prosocial leisure or recreational activities during the past 30 days.
1= Negative; 5=About the Same; 10=Positive
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4. Select the number representing your view of the client’s progress on dealing with any alcohol or substance use needs during the past 30 days.
1= Negative; 5=About the Same; 10=Positive
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5. Select the number representing your view of the client’s progress on coping with any mental health needs or concerns during the past 30 days.
1= Negative; 5=About the Same; 10=Positive
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6. Select the number representing your view of the client’s progress in addressing any other relevant areas during the past 30 days:
1= Negative; 5=About the Same; 10=Positive
Area 1:
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6. Select the number representing your view of the client’s progress in addressing any other relevant areas during the past 30 days:
1= Negative; 5=About the Same; 10=Positive
Area 2:
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7. Mark any change(s)/actions taken related to this client during the past 30 days:
If yes, please specify
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| Yes[,] | No[,] | Not Applicable[,] | Specify | | | | | | | | | Drug testing added as supervision requirement | | | | | Increased reporting requirements | | | | | Decreased reporting requirements | | | | | Treatment program referral: ____ (program type) | | | | | Mental health assessment referral | | | | | Mental health treatment referral | | | | | Referral to a physician or clinic: _____ (reason) | | | | | Other change(s): ____(specify) | | | | |
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8. On a scale of 1 to 5 indicate the degree to which you agree with the statements.
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