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 50 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: |__|__| : |__|__|

CC_MO CC_DY CC_YR CC_START CC_END

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

CC_MOM CC_CHLD

EVALUATION PHASE: Intake |__|1 Delivery |__|2

CC_INTERVIEW_TYPE

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

CC_INTERVIEWER CC_SITE

CHILD DATA COLLECTION TOOL

Instructions: This demographic information is to be obtained during the first 30 days of intake (or delivery), and is focused 

on the background of a single child. This information is to be completed on each child receiving treatment services 

(children who have received assessment and who have received an individual treatment plan).

This tool consists of Part 1 to be completed by a children’s specialist through interviewing the mother; and Part 2 to 

be completed by a health care professional through interviewing the mother and reviewing the medical records. 

PART 1. BIOLOGICAL BACKGROUND

1. Age

CC_AGE_RANGE 5 years or less .................................................................................. 1

6 to 10 years..................................................................................... 2

11 to 14 years................................................................................... 3

15 to 17 years................................................................................... 4

2. Gender

CC_GENDER

Male ................................................................................................. 1

Female ............................................................................................. 2

3. Ethnic/Racial Identification

Ethnicity

CC_HISPANIC_LATINO

Hispanic or Latino ............................................................................. 1

Not Hispanic or Latino....................................................................... 2

Race (Select all that apply.)

CC_RACE_BLACK Black or African American ................................................................. 1

CC_RACE_ALASKA_NATIVE Alaska Native.................................................................................... 2

CC_RACE_AMERICAN_INDIAN American Indian................................................................................ 3

CC_RACE_ASIAN Asian................................................................................................ 4

CC_RACE_NATIVE_HAWAIIAN Native Hawaiian or Other Pacific Islander .......................................... 5

CC_RACE_WHITE White................................................................................................ 6

2 0
2

4. What is the formal relationship of this child to the mother, with whom they have been admitted for 

receiving treatment services?

CC_RELATIONSHIP

Biological .......................................................................................... 1

Step.................................................................................................. 2

Adopted............................................................................................ 3

Grandmother..................................................................................... 4

Aunt.................................................................................................. 5

Foster............................................................................................... 6

Other ................................................................................................ 7

5. Is the biological father still alive? 

CC_FATHER_STATUS

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

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

Don’t Know (but know who he is) ...................................................... -8

Don’t know who he is ........................................................................ 2

6. Is English the first and primary language spoken by this child?

CC_ENGLISH_PRIMARILY

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

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

N/A................................................................................................... -1

7. Does this child have any of the following intelligence-related challenges? (Select all that apply.)

CC_MENTAL_RETARDATION Mental retardation ............................................................................. 1

CC_DOWN_SYNDROME Down Syndrome ............................................................................... 2

CC_AUTISM Autistic Spectrum Disorders............................................................... 3

CC_UNKNOWN UNKNOWN....................................................................................... -8

8. Does this child have any of the following physical challenges? (Select all that apply.)

CC_BLINDNESS Blindness.......................................................................................... 1

CC_DEAFNESS Deafness .......................................................................................... 2

CC_CEREBRAL_PALSY Cerebral Palsy .................................................................................. 3

CC_HANDICAPPED Inability to be Mobile (Handicapped) .................................................. 4

CC_MUSCULAR_DYSTROPHY Muscular Dystrophy........................................................................... 5

CC_FACIAL_DISFIGUREMENT Facial Disfigurement.......................................................................... 6

CC_OTHER_CHALLENGE Other (specify) ___________________________________________ 7

CC_OTHER_CHALLENGE_OTH

9. Does this child have siblings? Include full, step, half, and adoptive siblings.

CC_SIBLINGS

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

No .................................................................................................... 0 GO TO Q10

10. What is this child’s placement amongst his/her siblings?

CC_RANK_AMONG_SIBLINGS

Oldest child....................................................................................... 1

Youngest child .................................................................................. 2

Middle child....................................................................................... 3

UNSURE - TOO MANY TO DETERMINE .......................................... 4

N/A - AN ONLY CHILD WITH NO SIBLINGS ..................................... -1
3

SOCIO-ECONOMIC BACKGROUND

11. In the past year – prior to admission – with whom did this child live with the most? 

CC_LIVE_WITH_MOST

Both biological father and mother....................................................... 1

Biological mother .............................................................................. 2

Biological father ................................................................................ 3

Biological grandparents (on the mother’s side)................................... 4

Biological grandparents (on the father’s side)..................................... 5

Biological aunt or uncle (on the mother’s side) ................................... 6

Biological aunt or uncle (on the father’s side) ..................................... 7

Foster care parents ........................................................................... 8

Adoptive parents ............................................................................... 9

Friends of the family.......................................................................... 10

UNKNOWN....................................................................................... -8

N/A................................................................................................... -1

12. If this child was living with someone other than the biological mother, was this a formal placement 

arranged by a Child Welfare System?

CC_FORMAL_PLACEMENT

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

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

N/A................................................................................................... -1

13. Who has legal custody of this child?

CC_LEGAL_CUSTODY

Both biological father and mother together......................................... 1

Biological mother .............................................................................. 2

Biological father ................................................................................ 3

Biological grandparents (on the mother’s side)................................... 4

Biological grandparents (on the father’s side)..................................... 5

Biological aunt or uncle (on the mother’s side) ................................... 6

Biological aunt or uncle (on the father’s side) ..................................... 7

Adoptive parents............................................................................... 8

State (Child welfare or foster care)..................................................... 9

CC_LEGAL_CUSTODY _OTH Other (specify) __________________________________________ 10

14. In the past year – prior to admission – how many months has this child ever been homeless (living on the 

streets, living in a homeless shelter, sleeping in empty buildings, etc.)?

CC_EVER_HOMELESS

0 months........................................................................................... 1

1 to 3 months ................................................................................... 2

4 to 6 months.................................................................................... 3

7 to 9 months.................................................................................... 4

10 to 12 months ................................................................................ 5
4

15. Where does this child’s main source of income or financial support come from? 

CC_MAIN_FINANCIAL_SUPPORT

Both biological father and mother....................................................... 1

Child support from biological father only............................................. 2

Biological mother only, through earned income .................................. 3

Biological father and spouse/domestic partner ................................... 4

Biological mother’s spouse/domestic partner...................................... 5

State/Public Assistance (SSDI – social security disability insurance;

WIC – women, infants, and children’s program; TANF –

temporary assistance to needy families; EMI – emergency

child insurance) ............................................................................. 6

Legally appointed guardian................................................................ 7

Members of the family....................................................................... 8

Friends of the family.......................................................................... 9

Nonlegal income............................................................................... 10

CC_MAIN_FINANCIAL_SUPPORT_OTH Other (specify)___________________________________________ 11

16. Where does this child’s main source of health care coverage/insurance come from?

CC_MAIN_HEALTH_CARE

Biological parents’ health insurance................................................... 1

Biological grandparents’ health insurance .......................................... 2

Legal guardians’ health insurance...................................................... 3

State/Public Assistance (Medicaid) .................................................... 4

Federal Assistance (Indian Health Service, VA, etc.).......................... 5

Nowhere – doesn’t have any ............................................................ 6

17. In the past 2 years, how many different states has this child lived in?

CC_5YRS_STATES_LIVED

One.................................................................................................. 1

Two .................................................................................................. 2

Three................................................................................................ 3

Four.................................................................................................. 4

Five.................................................................................................. 5

More than five................................................................................... 6

18. In the past 2 years, how many different neighborhoods has this child lived in?

CC_5YRS_NEIGHBORHOODS_LIVED

One.................................................................................................. 1

Two .................................................................................................. 2

Three................................................................................................ 3

Four.................................................................................................. 4

Five.................................................................................................. 5

More than five................................................................................... 6

19. What type of structure has this child lived in most of his/her life?

CC_TYPE_STRUCTURE

House............................................................................................... 1

Apartment 2

Trailer Home..................................................................................... 3

This Facility....................................................................................... 4

Hospital ............................................................................................ 5

CC_TYPE_STRUCTURE_OTH Other (specify) ___________________________________________ 6
5

LEGAL BACKGROUND

20. To your knowledge, how many Child Protective Services (CPS) abuse reports have ever been made on 

this child, even if they were not substantiated (founded)?

CC_NUM_ABUSE_REPORTS

None ................................................................................................ 0

One.................................................................................................. 1

Two .................................................................................................. 2

Three................................................................................................ 3

Four.................................................................................................. 4

Five.................................................................................................. 5

More than five................................................................................... 6

21. To your knowledge, how many CPS neglect reports have ever been made on this child, even if they were 

not substantiated (founded)? 

CC_NUM_NEGLECT_REPORTS

None ................................................................................................ 0

One.................................................................................................. 1

Two .................................................................................................. 2

Three................................................................................................ 3

Four.................................................................................................. 4

Five.................................................................................................. 5

More than five................................................................................... 6

22. Has this child ever been removed from anyone’s care by CPS?

CC_REMOVED_ANYONES_CARE

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

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

Don’t Know....................................................................................... -8

23. How many times has this child been removed from your care by CPS?

CC_REMOVED_YOUR_CARE

None ................................................................................................ 0

One time........................................................................................... 1

Two times......................................................................................... 2

Three times....................................................................................... 3

Four times ........................................................................................ 4

Five times......................................................................................... 5

More than five times.......................................................................... 6

N/A................................................................................................... -1

Don’t Know....................................................................................... -8

24. For how many total months has this child been removed from your care by CPS?

CC_MONTHS_REMOVED

Less than 1 month............................................................................. 1

1 to 3 months.................................................................................... 2

4 to 6 months.................................................................................... 3

7 to 12 months.................................................................................. 4

13 to 24 months ................................................................................ 5

25 to 36 months................................................................................ 6

37 to 48 months ................................................................................ 7

More than 48 months ........................................................................ 8

N/A................................................................................................... -1

Don’t Know....................................................................................... -8
6

25. Which of the following caused removal of this child by CPS? (Select all that apply.)

CC_ REMOVED_PHYSICAL Child abuse (physical)....................................................................... 1

CC_ REMOVED_NEGLECT Child abuse (neglect) ........................................................................ 2

CC_ REMOVED_SEXUAL Child abuse (sexual).......................................................................... 3

CC_ REMOVED_EMOTIONAL Child abuse (emotional/mental) ......................................................... 4

 CC_ REMOVED_ILLEGAL_ACT Involvement of child in illegal activities ............................................... 5

CC_ REMOVED_UNDER_INFL Child found to be under the influence of alcohol and/or other drugs..... 6

CC_REASON_OTHER Other (specify)___________________________________________ 7

CC_REASON_OTHER_OTH

CC_REASON_NA N/A................................................................................................... -1

26. Has this child ever been involved with the criminal or Juvenile Justice System been referred, detained or 

arrested for: breaking the law, truancy, running away, violating curfews, drug use or selling, etc.]?

CC_JJS_INVOLVED

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

27. At what age did this child’s involvement with the criminal or Juvenile Justice System begin?

CC_AGE_JJS_INVOLVED

None, not ever involved..................................................................... 0

1 month to 5 years ............................................................................ 1

6 to 10 years..................................................................................... 2

11 to 14 years................................................................................... 3

15 to 17 years................................................................................... 4

28. How many times has this child been involved with the criminal or juvenile justice system? 

CC_TIMES_JJS_INVOLVED

None ................................................................................................ 0

One time........................................................................................... 1

Two times......................................................................................... 2

Three times....................................................................................... 3

Four times ........................................................................................ 4

Five times......................................................................................... 5

More than five times.......................................................................... 6

29. How many months has this child been legally detained?

CC_LEGALLY_DETAINED

None ................................................................................................ 0

Less than 1 month............................................................................. 1

1 to 3 months.................................................................................... 2

4 to 6 months.................................................................................... 3

7 to 12 months.................................................................................. 4

13 to 24 months ................................................................................ 5

25 to 36 months ................................................................................ 6

37 to 48 months ................................................................................ 7

More than 48 months ........................................................................ 8

30. Has this child ever been involved with gangs (belonged to a gang associated with gang members)?

CC_GANG_INVOLVED

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

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

Don’t Know....................................................................................... -8
7

31. Has this child ever witnessed acts of violence in their home, community, or school?

CC_WITNESSED_VIOLENCE

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

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

Don’t Know....................................................................................... -8

32. Has this child ever been exposed to trauma (e.g. drive by shootings, school schootings, fights)in their 

home, community, or school?

CC_EXPOSED_TO_TRAUMA

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

33. Has this child ever been a victim of violence? (Select all that apply.)

CC_VICTIM_HOME Yes (in the home).............................................................................. 1

CC_VICTIM_SCHOOL Yes (at school).................................................................................. 2

CC_VICTIM_NEIGHBORHOOD Yes (in the neighborhood) ................................................................. 3

CC_VICTIM_ANIMAL Yes (by an animal) ............................................................................ 4

CC_VICTIM_NO No .................................................................................................... 0

CC_VICTIM_DK Don’t Know ....................................................................................... -8

34. Has this child ever committed any acts of violence with animals?

CC_PETS_VIOLENCE 

Yes (without weapons)...................................................................... 1

Yes (with weapons)........................................................................... 2

Yes (both with and without weapons)................................................. 3

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

Don’t Know ...................................................................................... -8

35. Has this child ever committed any acts of violence with humans?

CC_HUMANS_VIOLENCE

Yes (without weapons)...................................................................... 1

Yes (with weapons)........................................................................... 2

Yes (both with and without weapons)................................................. 3

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

Don’t Know ...................................................................................... -8

36. Has this child ever set fires?

CC_SET_FIRES

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

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

Don’t Know....................................................................................... -8
8

EDUCATIONAL BACKGROUND

37. Which of the following educational levels is this child in? (Please circle only one response.)

CC_EDUCATION

Day Care only................................................................................... 1

Preschool ......................................................................................... 2

Kindergarten..................................................................................... 3

Grade 1 ─ 5...................................................................................... 4

Grade 6 ─ 8...................................................................................... 5

Grade 9 ─ 12.................................................................................... 6

None ................................................................................................ 0

Don’t Know....................................................................................... -8

38. Is this child at the appropriate educational level for their age?

CC_APPROPRIATE_GRADE

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

39. Has this child ever been held back in school?

CC_HELD_BACK

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

40. If this child is in school, is their progress in school reflective of them being an...?

CC_GRADE

‘A’ student,........................................................................................ 1

‘B’ student,........................................................................................ 2

‘A & B’ student, ................................................................................. 3

‘C’ student, ....................................................................................... 4

‘D’ student, or.................................................................................... 5

‘F’ student?....................................................................................... 6

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

41. If this child is in school, indicate what type of attendance pattern this child has in school.

CC_ATTENDANCE

Poor (misses a lot of days) ................................................................ 1

Fair (misses some days) ................................................................... 2

Good (misses only a few days).......................................................... 3

Excellent (goes consistently) ............................................................. 4

Don’t Know ...................................................................................... -8

N/A................................................................................................... -1
9

42. Which of the following extracurricular activities does this child participate in? (Select all that apply.)

CC_EXTRACUR_SPORTS Sports............................................................................................... 1

CC_EXTRACUR_MUSIC Music................................................................................................ 2

CC_EXTRACUR_DANCE Dance............................................................................................... 3

CC_EXTRACUR_DRAMA Drama .............................................................................................. 4

CC_EXTRACUR_COMM_SERVICE Community Service........................................................................... 5

CC_EXTRACUR_CHURCH Religious Activities ............................................................................ 6

CC_EXTRACUR_NONE None ................................................................................................ 0

CC_EXTRACUR_NA N/A................................................................................................... -1

CC_EXTRACUR_OTHER Other (specify) ___________________________________________ 7

CC_EXTRACUR_OTHER_OTH

43. Has this child been assessed for any possible learning disabilities?

CC_DISABILITY_ASSESSED

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

44. Has this child been diagnosed with a learning disability?

CC_DISABILITY_DIAGNOSED

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

45. Has this child ever received Ritalin or any other prescription medication for attention deficit disorder 

(ADD) or attention deficit and hyperactivity disorder (ADHD)?

CC_ADD_ADHD_MEDS

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

SPIRITUAL BACKGROUND

46. How often does this child attend religious services?

CC_PLACE_WORSHIP

Once a week..................................................................................... 1

Once a month................................................................................... 2

Four times a year.............................................................................. 3

During holidays ................................................................................. 4

Twice a year ..................................................................................... 5

Once a year...................................................................................... 6

Not at all ........................................................................................... 0

N/A................................................................................................... -1

47. How often does this child experience prayer, either by doing it themselves or with someone else?

CC_TIMES_PRAY

Every day/night ................................................................................. 1

Few times a week ............................................................................. 2

Once a week..................................................................................... 3

Once a month................................................................................... 4

Few times a year............................................................................... 5

Only at holiday ceremonies ............................................................... 6

Only to bless a meal.......................................................................... 7

Not at all ........................................................................................... 0
10

48. Which of the following spiritual activities does this child experience most?

CC_MEDITATION

Reading or being read to from inspirational sources ........................... 1

Listening to relaxation/ inspirational music ......................................... 2

Listening to stories ............................................................................ 3

Finding a quiet spot........................................................................... 4

Taking nature/environmental appreciation walks ................................ 5

CC_MEDITATION_OTH Other (specify) ___________________________________________ 6

None at all ....................................................................................... 0

49. Does this child believe in a ‘Higher Power’ of any kind?

CC_BELIEVE_HIGHER_POWER

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

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

DON’T KNOW................................................................................... -8

N/A (TOO YOUNG)........................................................................... -1

RECREATION/LEISURE BACKGROUND

Yes No Don’t Know N/A

50. If this child is preschool or older, has he/she gone to museums or 

other historical sites of any kind?.............................................

CC_MUSEUMS

1 2 -8 -1

51. If this child is preschool or older, has he/she played in any 

community/neighborhood team/group sports?........................

CC_GROUP_SPORTS

1 2 -8 -1

52. Has this child ever been to an amusement park or local carnivals or 

fairs?..........................................................................................

CC_AMUSEMENT_PARK

1 2 -8 -1

53. Has this child ever been on any picnics (family, community, 

church, school)?........................................................................

CC_PICNIC

1 2 -8 -1

54. Does this child go to arcades or a friend’s home to play games?

CC_ARCADES

1 2 -8 -1

55. Does this child play video games at home? .............................

CC_VIDEOS

1 2 -8 -1

56. Does this child watch television at home?................................

CC_TV

1 2 -8 -1

57. Does this child participate in family games, such as cards, 

checkers, or Backgammon?......................................................

CC_FAMILY_GAMES

1 2 -8 -1

58. Does this child go out to the movies?.......................................

CC_MOVIES

1 2 -8 -1

59. Does this child have hobbies, such as arts and crafts or reading?

CC_HOBBIES

1 2 -8 -1

60. Does this child have access to the Internet outside of school?

CC_INTERNET

1 2 -8 -1
11

BACKGROUND OF PARENTAL RELATIONSHIPS

61. How would you describe your efforts at initiating involvement in this child’s life?

CC_MOTHER_INVOLVE_EFFORT

No effort at all ................................................................................... 1

Efforts are not good .......................................................................... 2

Efforts are good ................................................................................ 3

Efforts are very good......................................................................... 4

Efforts are excellent .......................................................................... 5

Don’t Know....................................................................................... -8

Biological mother deceased............................................................... -1

62. How would you describe the biological father’s efforts at initiating involvement in this child’s life?

CC_FATHER_INVOLVE_EFFORT

No effort at all ................................................................................... 1

Efforts are not good .......................................................................... 2

Efforts are good ................................................................................ 3

Efforts are very good......................................................................... 4

Efforts are excellent .......................................................................... 5

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

63. If this child’s biological father does not live with him/her, which of the additional ways is there 

involvement in his/her life? (Select all that apply.)

CC_FATHER_INV_MONETARY Monetary support .............................................................................. 1

CC_FATHER_INV_CHILD_CARE Child care ......................................................................................... 2

CC_FATHER_INV_REG_VISITS Visits on a regular basis .................................................................... 3

CC_FATHER_INV_IRREG_VISITS Visits on an irregular basis................................................................. 4

CC_FATHER_INV_TELEPHONE Telephone contact............................................................................. 5

CC_FATHER_INV_LETTERS Letters in the mail.............................................................................. 6

CC_FATHER_INV_OTHER Other (specify) ___________________________________________ 7

CC_FATHER_INV_OTHER_OTH

CC_FATHER_INV_NONE None ................................................................................................ 0

CC_FATHER_INV_NA N/A................................................................................................... -1

64. Do you believe it is appropriate for this child to have contact with his/her biological father?

CC_APPROPRIATE_FATHER_CONTACT

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

65. Did this child’s biological father accompany his/her mother to prenatal visits?

CC_FATHER_PRENATAL_VISITS

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

66. Was this child’s biological father present at his/her birth?

CC_FATHER_PRESENT_AT_BIRTH

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1
12

67. Is this child’s biological father a substance abuser/addict?

CC_FATHER_AN_ADDICT

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

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

Don’t Know....................................................................................... -8

N/A................................................................................................... -1

68. If this child has no contact with his/her biological mother, which of the following persons serves as a 

mother figure? (Select all that apply.)

CC_MOTHER_FIGURE_STEP Step mother...................................................................................... 1

CC_MOTHER_FIGURE_ADOPTIVE Adoptive mother................................................................................ 2

CC_MOTHER_FIGURE_GM Grandmother..................................................................................... 3

CC_MOTHER_FIGURE_FSO Father’s significant other.................................................................... 4

CC_MOTHER_FIGURE_PLAY Play mother ...................................................................................... 5

CC_MOTHER_FIGURE_AUNT Aunt.................................................................................................. 6

CC_MOTHER_FIGURE_FOSTER Foster............................................................................................... 7

CC_MOTHER_FIGURE_OTHER Other (specify) ___________________________________________ 8

CC_MOTHER_FIGURE_OTHER_OTH

CC_MOTHER_FIGURE_NOONE No one ............................................................................................. 0

CC_MOTHER_FIGURE_NA N/A (has contact with biological mother)............................................. -1

69. If this child has no contact with his/her biological father, which of the following persons serves as a father 

figure? (Select all that apply.)

CC_FATHER_FIGURE_STEP Step father........................................................................................ 1

CC_FATHER_FIGURE_ADOPTIVE Adoptive father.................................................................................. 2

CC_FATHER_FIGURE_GF Grandfather ...................................................................................... 4

CC_FATHER_FIGURE_MSO Mother’s significant other................................................................... 3

CC_FATHER_FIGURE_PLAY Play father ........................................................................................ 5

CC_FATHER_FIGURE_UNCLE Uncle................................................................................................ 6

CC_FATHER_FIGURE_OTHER Other (specify) ___________________________________________ 7

CC_FATHER_FIGURE_NOONE No one ............................................................................................. 0

CC_FATHER_FIGURE_NA N/A (has contact with biological father) .............................................. -1

70. How would you describe this child’s relationship with his/her mother figure?

CC_RELATIONSHIP_MOTHER_FIGURE

Not close at all .................................................................................. 1

Not very close................................................................................... 2

Somewhat close ............................................................................... 3

Quite close ....................................................................................... 4

Extremely close ................................................................................ 5

Don’t Know ...................................................................................... -8

N/A (is with biological mother) ........................................................... -1

71. How would you describe this child’s relationship with his/her father figure?

CC_RELATIONSHIP_FATHER_FIGURE

Not close at all .................................................................................. 1

Not very close................................................................................... 2

Somewhat close ............................................................................... 3

Quite close ....................................................................................... 4

Extremely close ................................................................................ 5

Don’t Know ...................................................................................... -8

N/A (is with biological father) ............................................................. -1
13

72. Is this child’s mother figure a substance abuser/addict? 

CC_MOTHER_FIGURE_ADDICT

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

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

Don’t Know....................................................................................... -8

N/A (is with biological mother) ........................................................... -1

73. Is this child’s father figure a substance abuser/addict? 

CC_FATHER_FIGURE_ADDICT

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

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

Don’t Know....................................................................................... -8

N/A (is with biological father) ............................................................ -1

ALCOHOL AND OTHER DRUG USE/INTERACTION BACKGROUND

Yes No Don’t Know

N/A

(child too young)

CC_EVER_NONITENDED_USE

74. Has this child ever taken prescription medicine 

for a purpose other than its intended use, either 

taken on their own or given by someone else?................................ 1 0 -8 -1

CC_EVER_OVER_COUNTER_MEDS

75. Has this child ever used store bought (over-thecounter) medications inappropriately? ................................ 1 0 -8 -1

CC_EVER_DRANK_ALCOHOL

76. Has this child ever drank any alcohol (beer, 

wine, hard liquor)?................................................................ 1 0 -8 -1

CC_EVER_TOBACCO

77. Has this child ever used tobacco products?................................ 1 0 -8 -1

CC_EVER_ILLEGAL_DRUGS

78. Has this child ever used illegal drugs 

(marijuana, hallucinogens, amphetamines, 

cocaine, inhalants)?................................................................1 0 -8 -1

CC_EVER_TRANSPORT_DRUGS

79. Has this child ever been a part of transporting 

drugs in any way?................................................................ 1 0 -8 -1

CC_EVER_LOOKOUT

80. Has this child ever participated in being a 

‘lookout’ for drug dealers? .......................................... 1 0 -8 -1

CC_EVER_SELLING

81. Has this child ever participated in selling 

drugs?........................................................................... 1 0 -8 -1

CC_EVER_ABOUT_GUARDIAN_ABUSE

82. Has this child ever voiced any negative 

thoughts or feelings about his/her guardian’s 

alcohol or drug use?..................................................... 1 0 -8 -1

CC_EVER_LIVED_ DRUG_ENV

83. Has this child ever lived in an environment 

where drugs were manufactured, used, or 

sold? ............................................................................. 1 0 -8 -1
14

HEALTH BACKGROUND

Yes No Don’t Know

N/A

(child too young)

CC_PRENATAL_VISITS

84. Did this child receive any pre-birth health care 

through recommended pre-natal visits by the 

mother? .............................................................................................. 1 0 -8 -1

CC_TEST_POSITIVE_AT_BIRTH

85. Did this child test positive for any alcohol or 

drugs at birth? ................................................................ 1 0 -8 -1

CC_ICU_AT_BIRTH

86. Did this child need special care services or 

equipment at birth, such as ICU or detox?................................ 1 0 -8 -1

CC_ONCE_YR_CHECKUP

87. Does this child go to the doctor or get a checkup at least once a year?................................................................ 1 0 -8 -1

CC_ONCE_YR_DENTIST

88. Does this child go to the dentist or get a checkup at least once a year?................................................................ 1 0 -8 -1

CC_UPDATED_IMMUNIZATION

89. Is this child’s immunization schedule complete 

and updated for his/her age?.............................................................. 1 0 -8 -1

CC_HIV_POSITIVE_AT_BIRTH

90. Did this child test HIV positive at birth?................................ 1 0 -8 -1

None

One 

time

Two 

times

Three 

times

Four 

times

Five 

times

More 

than five 

times

CC_TIMES_HOSP_PHYSICAL

91. How many times has this child received 

treatment for any physical/ medical health 

problems during his/her lifetime? ................................ 0 1 2 3 4 5 6

CC_TIMES_HOSP_MENTAL

92. How many times has this child received 

treatment for any mental/psychiatric health 

problems during his/her lifetime? ................................ 0 1 2 3 4 5 6

CC_TIMES_ER_PHYSICAL

93. How many times has this child been to the 

Emergency Room due to any physical/medical 

health problems during his/her lifetime? ..................... 0 1 2 3 4 5 6

CC_TIEMS_ER_MENTAL

94. How many times has this child been to the 

Emergency Room due to any mental/ 

psychiatric or medical/health problems during 

his/her lifetime? ............................................................ 0 1 2 3 4 5 6
15

PART 2

DATE: |__|__| |__|__| |__|__|__|__| PERSON COMPLETING |_______________|

CC_MO CC_DY CC_YR CC_INTERVIEWER 

Part 2 is to be completed by a health care professional through interviewing the mother and reviewing the medical 

records. 

Please indicate what this child’s experience has been with the following childhood illnesses/conditions/diseases during 

his/her lifetime.

Does this child have a history of...

A. Asthma

CC_ASTHMA

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_ASTHMA_YES_1 a. Ever been treated for it?............................................ 1 0

CC_ASTHMA_YES_2 b. Currently under medical supervision? ........................ 2 0

B. Diabetes

CC_DIABETES

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_DIABETES_YES_1 a. Ever been treated for it?............................................. 1 0

CC_DIABETES_YES_2 b. Currently under medical supervision?......................... 2 0

C. Sickle Cell Anemia

CC_SICKLE_CELL_ANEMIA

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_SICKLE_CELL_ANEMIA_YES_1 a. Ever been treated for it?............................................ 1 0

CC_SICKLE_CELL_ANEMIA_YES_2 b. Currently under medical supervision? ........................ 2 0

D. Obesity

CC_OBESITY

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_OBESITY_YES_1 a. Ever been treated for it?............................................ 1 0

CC_OBESITY_YES_2 b. Currently under medical supervision? ........................ 2 0

2 0
16

E. Hypertension (high blood pressure)

CC_HYPERTENSION

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_HYPERTENSION_YES_1 a. Ever been treated for it?............................................ 1 0

CC_HYPERTENSION_YES_2 b. Currently under medical supervision? ........................ 2 0

F. Frequent Colds, Bronchitis, Other Upper Respiratory Infections

CC_COLDS

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_COLDS_YES_1 a. Ever been treated for it?............................................ 1 0

CC_COLDS_YES_2 b. Currently under medical supervision? ........................ 2 0

G. Allergies (pollen, mold, house dust mites, animal dander and saliva, and industrial chemicals)

CC_ALLERGIES

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_ALLERGIES_YES_1 a. Ever been treated for it?............................................ 1 0

CC_ALLERGIES_YES_2 b. Currently under medical supervision? ........................ 2 0

H. Allergies (medicine)

CC_MEDICINE_ALLERGIES

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_MEDICINE_ALLERGIES_YES_1 a. Ever been treated for it?............................................ 1 0

CC_MEDICINE_ALLERGIES_YES_2 b. Currently under medical supervision? ........................ 2 0

I. Allergies (insect bites and stings)

CC_STING_ALLERGIES

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_STING_ALLERGIES_YES_1 a. Ever been treated for it?............................................ 1 0

CC_STING_ALLERGIES_YES_2 b. Currently under medical supervision? ........................ 2 0

J. Ear Infections

CC_EAR_INFECTIONS

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_EAR_INFECTIONS_YES_1 a. Ever been treated for it?............................................ 1 0

CC_EAR_INFECTIONS_YES_2 b. Currently under medical supervision? ........................ 2 0
17

K. Communicable Diseases (Measles, Mumps, Rubella, Chicken Pox)

CC_MEASLES

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_MEASLES_YES_1 a. Ever been treated for it?............................................ 1 0

CC_MEASLES_YES_2 b. Currently under medical supervision? ........................ 2 0

L. Leukemia or other childhood cancers

CC_LEUKEMIA

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_LEUKEMIA_YES_1 a. Ever been treated for it?............................................ 1 0

CC_LEUKEMIA_YES_2 b. Currently under medical supervision? ........................ 2 0

M. HIV/AIDS and/or other sexually transmitted diseases

CC_HIV_AIDS

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_HIV_AIDS_YES_1 a. Ever been treated for it?............................................ 1 0

CC_HIV_AIDS_YES_2 b. Currently under medical supervision? ........................ 2 0

N. Fetal Alcohol Spectrum or Fetal Alcohol Effects

CC_FETAL_ALCOHOL_SYND

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_FETAL_ALCOHOL_SYND_YES_1 a............................................................................... 1 0

CC_FETAL_ALCOHOL_SYND_YES_2 b............................................................................... 2 0

O. Toothaches, cavities, gum disease, and other dental problems

CC_DENTAL

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_DENTAL_YES_1 a. Ever been treated for it?............................................ 1 0

CC_DENTAL_YES_2 b. Currently under medical supervision? ........................ 2 0

P. Blurred vision, near sightedness, farsightedness

CC_VISION

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_VISION_YES_1 a. Ever been treated for it?............................................ 1 0

CC_VISION_YES_2 b. Currently under medical supervision? ........................ 2 0
18

Q. Physical trauma from accidents (car, bicycle, sports)

CC_ACCIDENTS

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_ACCIDENTS_YES a. Ever been treated for it?............................................ 1 0

CC_ACCIDENTS_YES b. Currently under medical supervision? ........................ 2 0

R. Urinary tract infections

CC_URINARY_INFECTION

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_URINARY_INFECTION_YES_1 a. Ever been treated for it?............................................ 1 0

CC_URINARY_INFECTION_YES_2 b. Currently under medical supervision? ........................ 2 0

S. Skin Diseases (psoriasis, excema)

CC_SKIN

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_SKIN_YES_1 a. Ever been treated for it?............................................ 1 0

CC_SKIN_YES_2 b. Currently under medical supervision? ........................ 2 0

T. Pink Eye (conjunctivitis), Head Lice, or Ringworm

CC_MEASLES

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_MEASLES_YES_1 a. Ever been treated for it?............................................ 1 0

CC_MEASLES_YES_2 b. Currently under medical supervision? ........................ 2 0

U. Anxiety or Depression (problem with nerves or mood)

CC_ANXDEPRESS

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_ ANXDEPRESS _YES_1 a. Ever been treated for it?............................................ 1 0

CC_ANXDEPRESS_YES_2 b. Currently under medical supervision? ........................ 2 0

V. Attention-deficit/hyperactivity disorder (ADHD)

CC_ADHD

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_ADHD_YES_1 a. Ever been treated for it?............................................ 1 0

CC_ADHD_YES_2 b. Currently under medical supervision? ........................ 2 0
19

W. Eating disorder (anorexia, bulimia, feeding problems)

CC_EATING_DISORDER

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_EATING_DISORDER_YES_1 a. Ever been treated for it?............................................ 1 0

CC_EATING_DISORDER_YES_2 b. Currently under medical supervision? ........................ 2 0

X. Enuresis (bedwetting) or Encopresis (repeated passing of feces in inappropriate places, 

whether voluntary or involuntary)

CC_ENURENCO

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_ENURENCO_YES_1 a. Ever been treated for it?............................................ 1 0

CC_ENURENCO_YES_2 b. Currently under medical supervision? ........................ 2 0

Y. Self-injurious behaviors (head banging, cutting, biting, scratching)

CC_SELF_INJURIOUS

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_SELF_INJURIOUS_YES_1 a. Ever been treated for it?............................................ 1 0

CC_SELF_INJURIOUS_YES_2 b. Currently under medical supervision? ........................ 2 0

Z. Uncontrolled anger

CC_UNCONTROL_ANGER

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_UNCONTROL_ANGER_YES_1 a. Ever been treated for it?............................................ 1 0

CC_UNCONTROL_ANGER_YES_2 b. Currently under medical supervision? ........................ 2 0

AA. Developmental delay/disorder in age appropriate motor skills

CC_MOTOR_SKILLS

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_MOTOR_SKILLS_YES_1 a. Ever been treated for it?............................................ 1 0

CC_MOTOR_SKILLS_YES_2 b. Currently under medical supervision? ........................ 2 0

BB. Developmental delay/disorder in age appropriate communication 

CC_COMMUNICATION

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_COMMUNICATION_YES_1 a. Ever been treated for it?............................................ 1 0

CC_COMMUNICATION_YES_2 b. Currently under medical supervision? ........................ 2 0
20

CC. Developmental delay/disorder in age appropriate cognition

CC_COGNITION

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_COGNITION_YES_1 a. Ever been treated for it?............................................ 1 0

CC_COGNITION_YES_2 b. Currently under medical supervision? ........................ 2 0

DD. Extreme reaction to stimulation

CC_STIMLUATION

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

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

Don’t Know....................................................................................... -8

IF YES, Yes No

CC_STIMULATION_YES_1 a. Ever been treated for it?............................................ 1 0

CC_STIMULATION_YES_2 b. Currently under medical supervision? ........................ 2 0

Developed by Karen Allen, Ph.D., Belinda Biscoe, Ph.D., and Linda White Young, M.S.W.

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

CC_2006.00