Download:
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pdfOMB # 0930- XXXX
Expiration Date: xx/xx/xxxx
PCAP Client Module
Monthly Update
Agency Name: ___________________________
Client #: __ __ __ __ __ __
Site Name: ______________________________
Date: __ __ / __ __ / __ __ __ __
Complete this form at end of every month.
Monthly update for the month of:
January
July
Year:
__ __ __ __
February
August
March
April
September October
No
A. Was client seen this month (face-to face)?
May
November
June
December
Yes
If not at least once, please explain: ____________________________________________________________
B. If client has disappeared, are you in contact with a tracing source?
No
Yes
N/A
Who? ____________________________________________
How long has she been missing? ____________________________________________
What have you done to try to find client? ________________________________________________________
C. Client location is known, but she is avoiding contact:
No
D. How many times was target child seen this month (face-to face)?
__ __
Yes
N/A
UNKNOWN
IN THE PAST MONTH, did client:
1. Use illicit drugs?
If No or Unknown, skip to Question 2
No
Yes
If yes, what? (check yes or no for each):
a. Cocaine
b. Heroin
c. Marijuana
d. Methamphetamine
e. Other (specify below)
No or Don’t Know
No or Don’t Know
No or Don’t Know
No or Don’t Know
No or Don’t Know
Yes
Yes
Yes
Yes
Yes
Specify Other: _________________________________
2a. Drink alcohol?
No
Yes, but not a problem
Yes, & has problem
2b. During the past 30 days, on how many days did you ________ days
drink one or more of an alcoholic beverage?
2c. 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
2d. 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
3. Relapse? (alcohol or drugs)
No
Not Abstinent
4. Any alcohol/drug treatment?
No
Yes, In progress Dropped
Once
More than Once
Yes, Completed
a. Where / What kind? _________________________________________________________________
5. Is client using birth control regularly?
No
Yes, regularly
Only sometimes
a. What kind of birth control? ____________________________________________________________
6. Is client pregnant?
No
Yes
7. If client was pregnant this month but is not now,
outcome:
Page 1
Parent-Child Assistance Program (PCAP)
ADAI Sound Data Source—1/30/2006
Terminated
Miscarried
Resulted in birth University
N/A 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 6 hours 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: __ __ / __ __ / __ __ __ __
UNKNOWN
IN THE PAST MONTH, did client:
If Q8, 9, 10, or 11 YES, briefly note details in comments, if known
8.
Leave baby (TC or other) with inadequate or no caretaker?
No
Yes
N/A
9.
Put any of her children in unsafe situations?
No
Yes
N/A
10. Gain or lose custody of any child?
No Yes, temporary
Yes, permanent
N/A
a. If so, who? To who? _______________________________________________
No
Yes
a. Report made by:
Advocate
Other Person: _______________
b. Report made on:
Client
Other Person: _______________
c. Report made on behalf of:
Target Child
Other Child
11. Was a report made to CPS this past month?
If No report, Unknown, or N/A, skip to Question 12
N/A
Target Child+Others
d. Reason for report: _________________________________________________
Sources of income this month:
12. Any employment? (Her employment)
a. If employed, is her employment her main source of income?
13. Any TANF/Welfare? (Does not incl. food stamps, medical benefits)
a. If receiving TANF/Welfare, is it the main source of income?
No
Yes
No
Yes
No
Yes
No
Yes
N/A
N/A
14. List all other sources of income this month: ________________________________________________
Comments: _____________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Advocate #: __ __ __
ADAI Sound Data Source—1/30/2006
Page 2
Parent-Child Assistance Program (PCAP)
| File Type | application/pdf |
| File Title | 6 MonthlyUpdate.pub |
| Author | ShradLa |
| File Modified | 2009-07-13 |
| File Created | 2009-07-13 |