MARCH 21, 2006 FORMAT

Form Approved

OMB No. 0930-0269

Expiration Date 09-30-2007

Public reporting burden for this collection of information is estimated to average 15 minutes per response; 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 to SAMHSA Reports 

Clearance Officer, Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20857. 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 control number for this 

project is 0930-0269

DATE: |__|__| |__|__| |__|__|__|__| START TIME: |__|__| : |__|__| END TIME: |__|__| : |__|__|

WD_MO WD_DY WD_YR WD_START WD_END

MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

WD_MOM

EVALUATION PHASE: DISCHARGE |__|6

WD_INTERVIEW_TYPE

PERSON COMPLETING |_______________| GRANT# TI |__|__|__|__|__|

WD_INTERVIEWER WD_SITE

WOMEN’S DISCHARGE TOOL

At the time a woman is discharged from treatment, this is to be completed by project staff based on review of each 

woman’s treatment records. 

1. Length of stay

WD_LENGTH_STAY

Less than 30 days ............ 1

30 days ............................ 2

31 – 45 days .................... 3

46 – 60 days .................... 4

61 – 90 days .................... 5

91 – 120 days................... 6

121 – 180 days................. 7

181 – 270 days................. 8

More than 270 days.......... 9

2. Treatment completion

WD_TREATMENT_COMPLETION 

Yes .............................. 1

No ............................... 0

3. Goals of Treatment Plan

WD_TREATMENT_GOALS 

None achieved.............. 0

1⁄4 achieved .................. 1

1⁄2 achieved .................. 2

3⁄4 achieved .................. 3

All achieved.................. 4

In the following section, choose the response category that most closely describes the services received by this woman. 

Record the corresponding value in the box for each column: A – Services Received, B – Number of Sessions, and C –

Where and by Whom.

If a woman is given a N/A for receiving a service in Column A, then it is anticipated that the woman will also receive N/A or 

NONE in Columns B-C.

SERVICE/TREATMENT ACTIVITY

A

Services 

Received

B

Sessions

C

Where and 

by Whom

1. Outreach, Screening, and Assessment ....................................................... |___|

WD_STA01_A

|___|

WD_STA01_B

|___|

WD_STA01_C

2. Detoxification............................................................................................. |___|

WD_STA02_A

|___|

WD_STA02_B

|___|

WD_STA02_C

3. Case Management Services....................................................................... |___|

WD_STA03_A

|___|

WD_STA03_B

|___|

WD_STA03_C

4. Substance Abuse Education and Treatment................................................ |___|

WD_STA04_A

|___|

WD_STA04_B

|___|

WD_STA04_C

5. Physical Exam by Healthcare Providers (including height, weight, 

vital signs, BMI, body systems: respiratory, cardiac, 

gastrointestinal, genitor-urinary, skin, neurological) .....................................

|___|

WD_STA05_A

|___|

WD_STA05_B

|___|

WD_STA05_C

2 0
SERVICES RECEIVED

COLUMN ‘A’ RESPONSES

1 = Yes

0 = No

-1 = N/A

-8 = Don’t know

NUMBER OF SESSIONS

COLUMN ‘B’ RESPONSES

0 = No sessions

1 = Once

2 = Every few months

3 = Monthly 

4 = 2-3 x/month

5 = Weekly 

6 = 2-6 x/week

7 = Daily

-1 = N/A

WHERE AND BY WHOM

COLUMN ‘C’ RESPONSE

1 = On-site by PPW project staff

2 = On-site by another agency

3 = Off-site by PPW project staff

4 = Off-site by another agency 

5 = On-site by PPW parent organization staff

6 = Off-site by PPW parent organization staff

-1 = N/A

2

SERVICE/TREATMENT ACTIVITY (continued)

A

Services 

Received

B

Sessions

C

Where and 

by Whom

6. Laboratory Testing (urinalysis, complete blood count, electrolytes, 

HIV/AIDS and STDs)..................................................................................

|___|

WD_STA06_A

|___|

WD_STA06_B

|___|

WD_STA06_C

7. Education, Screening, Counseling, and Treatment of Hepatitis, 

HIV/AIDS, other STDs................................................................................

|___|

WD_STA07_A

|___|

WD_STA07_B

|___|

WD_STA07_C

8 Vision Screening (used standard eye charts) .............................................. |___|

WD_STA09_A

|___|

WD_STA09_B

|___|

WD_STA09_C

9. Speech and Hearing Assessment............................................................... |___|

WD_STA10_A

|___|

WD_STA10_B

|___|

WD_STA10_C

10. Dental Assessment (done by dentist).......................................................... |___|

WD_STA11_A

|___|

WD_STA11_B

|___|

WD_STA11_C

11. Nutritional Assessment (done by registered dietitian) .................................. |___|

WD_STA12_A

|___|

WD_STA12_B

|___|

WD_STA12_C

12. Medical Diagnosing and Follow-up Treatment............................................. |___|

WD_STA13_A

|___|

WD_STA13_B

|___|

WD_STA13_C

13. Prenatal Health Care.................................................................................. |___|

WD_STA14_A

|___|

WD_STA14_B

|___|

WD_STA14_C

14. Postpartum Health Care............................................................................. |___|

WD_STA14_A

|___|

WD_STA14_B

|___|

WD_STA14_C

15. Mental Health Assessment ........................................................................ |___|

WD_STA15_A

|___|

WD_STA15_B

|___|

WD_STA15_C

16. Mental Health Treatment............................................................................ |___|

WD_STA16_A

|___|

WD_STA16_B

|___|

WD_STA16_C

17. Trauma-informed services, including assessment and interventions for:

a. Emotional abuse ................................................................................. |___|

WD_STA17_

EMOTIONAL_A

|___|

WD_STA17_

EMOTIONAL_B

|___|

WD_STA17_

EMOTIONAL_C

b. Sexual abuse...................................................................................... |___|

WD_STA17_

SEXUAL_A

|___|

WD_STA17_

SEXUAL_B

|___|

WD_STA17_

SEXUAL_C

c. Physical abuse.................................................................................... |___|

WD_STA17_

PHYSICAL_A

|___|

WD_STA17_

PHYSICAL_B

|___|

WD_STA17_

PHYSICAL_C

18. Recreational Activity (field trips, movies, team sports, cultural 

experiences, picnics)..................................................................................

|___|

WD_STA18_A

|___|

WD_STA18_B

|___|

WD_STA18_C

19. Spiritual Activity (meditational activities, attendance at services, 

watching video tapes, listening to tapes, etc.)..............................................

|___|

WD_STA19_A

|___|

WD_STA19_B

|___|

WD_STA19_C
SERVICES RECEIVED

COLUMN ‘A’ RESPONSES

1 = Yes

0 = No

-1 = N/A

-8 = Don’t know

NUMBER OF SESSIONS

COLUMN ‘B’ RESPONSES

0 = No sessions

1 = Once

2 = Every few months

3 = Monthly 

4 = 2-3 x/month

5 = Weekly 

6 = 2-6 x/week

7 = Daily

-1 = N/A

WHERE AND BY WHOM

COLUMN ‘C’ RESPONSE

1 = On-site by PPW project staff

2 = On-site by another agency

3 = Off-site by PPW project staff

4 = Off-site by another agency 

5 = On-site by PPW parent organization staff

6 = Off-site by PPW parent organization staff

-1 = N/A

3

SERVICE/TREATMENT ACTIVITY (continued)

A

Services 

Received

B

Sessions

C

Where and 

by Whom

20. Employment Readiness, Training ............................................................... |___|

WD_STA20_A

|___|

WD_STA20_B

|___|

WD_STA20_C

21. Employment Placement ............................................................................. |___|

WD_STA21_A

|___|

WD_STA21_B

|___|

WD_STA21_C

22. Permanent Housing Arrangements............................................................. |___|

WD_STA22_A

|___|

WD_STA22_B

|___|

WD_STA22_C

23. Childcare................................................................................................... |___|

WD_STA23_A

|___|

WD_STA23_B

|___|

WD_STA23_C

24. Transportation ........................................................................................... |___|

WD_STA24_A

|___|

WD_STA24_B

|___|

WD_STA24_C

25. Mother-Child Parenting/Bonding Classes.................................................... |___|

WD_STA25_A

|___|

WD_STA25_B

|___|

WD_STA25_C

26. Mother/Child Counseling/Classes ............................................................... |___|

WD_STA26_A

|___|

WD_STA26_B

|___|

WD_STA26_C

27. Individual Psychiatric Therapy (based on psychiatric diagnosis)................... |___|

WD_STA27_A

|___|

WD_STA27_B

|___|

WD_STA27_C

28. Group Psychiatric Therapy (based on psychiatric diagnosis) ....................... |___|

WD_STA28_A

|___|

WD_STA28_B

|___|

WD_STA28_C

29. Individual Substance Abuse Counseling ..................................................... |___|

WD_STA29_A

|___|

WD_STA29_B

|___|

WD_STA29_C

30. Group Substance Abuse Counseling .......................................................... |___|

WD_STA30_A

|___|

WD_STA30_B

|___|

WD_STA30_C

31. Family Therapy.......................................................................................... |___|

WD_STA31_A

|___|

WD_STA31_B

|___|

WD_STA31_C

32. Educational Services (for GED and other educational needs) ...................... |___|

WD_STA32_A

|___|

WD_STA32_B

|___|

WD_STA32_C

33. Discharge Planning (including community reintegration).............................. |___|

WD_STA33_A

|___|

WD_STA33_B

|___|

WD_STA33_C

34. Planned or Arranged Post Residential Treatment Continuing Care .............. |___|

WD_STA34_A

|___|

WD_STA34_B

|___|

WD_STA34_C

35. Established Socio-economic Support at State and Federal Level 

(if eligible)..................................................................................................

|___|

WD_STA35_A

|___|

WD_STA35_B

|___|

WD_STA35_C

Not to be used without the written permission of Karen Allen, Ph.D. 

WD_2006.00