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: |__|__| : |__|__|

CD_MO CD_DY CD_YR CD_START CD_END

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

CD_MOM CD_CHLD

EVALUATION PHASE: Discharge |__|6 

CD_INTERVIEW_TYPE

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

CD_INTERVIEWER CD_SITE

CHILDREN’S DISCHARGE TOOL

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

treatment records. 

1. Length of stay

CD_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

CD_TREATMENT_COMPLETION 

Yes 1

No 0

3. Goals of Treatment Plan

CD_TREATMENT_GOALS 

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

1⁄4 achieved ............... 1

1⁄2 achieved ............... 2

3⁄4 achieved ............... 3

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

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’ RESPONSES

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

Choose the response category that most closely describes the servides received by this child. Record the corresponding 

value in the bos fore each column: A – Servies Received, B – Number of Sessions, and C – Where and by Whom.

If a child is given a N/A for receiving a service in Column A, then it is anticipated that the child 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. Developmental Assessment (based on standardized 

form/process)....................................................................................

|___|

CD_STA01_A

|___|

CD_ STA01_B

|___|

CD_ STA01_C

2. Physical Exam by Healthcare Providers (including height, 

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

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

|___|

CD_STA02_A

|___|

CD_ STA02_B

|___|

CD_ STA02_C

3. Laboratory Testing (urinalysis, complete blood count, 

electrolytes, HIV/AIDS & STDs).........................................................

|___|

CD_STA03_A

|___|

CD_ STA03_B

|___|

CD_ STA03_C

4. Immunization Updates ...................................................................... |___|

CD_STA04_A

|___|

CD_ STA04_B

|___|

CD_ STA04_C

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

CD_STA05_A

|___|

CD_ STA05_B

|___|

CD_ STA05_C

6. Speech and Hearing Assessment...................................................... |___|

CD_STA06_A

|___|

CD_ STA06_B

|___|

CD_ STA06_C

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

CD_STA07_A

|___|

CD_ STA07_B

|___|

CD_ STA07_C

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

CD_STA08_A

|___|

CD_ STA08_B

|___|

CD_ STA08_C

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

CD_STA09_A

|___|

CD_ STA09_B

|___|

CD_ STA09_C

10. Mental Status Exam for Children ....................................................... |___|

CD_STA10_A

|___|

CD_ STA10_B

|___|

CD_ STA10_C

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

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

|___|

CD_STA11_A

|___|

CD_ STA11_B

|___|

CD_ STA11_C

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

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

|___|

CD_STA12_A

|___|

CD_ STA12_B

|___|

CD_ STA12_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’ RESPONSES

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

13. Individual Nurturing (0 to 5 yrs) (this includes being held, 

rocked, infant massage/stimulation, reading to them, singing 

to/with them, listening to them and dialoguing with them) ...................

|___|

CD_STA13_A

|___|

CD_ STA13_B

|___|

CD_ STA13_C

14. Individual Counseling Related to Effects of Substance Abuse 

(5 to 17 yrs) ......................................................................................

|___|

CD_STA14_A

|___|

CD_ STA14_B

|___|

CD_ STA14_C

15. Substance Abuse Prevention Education/Classes ............................... |___|

CD_STA15_A

|___|

CD_ STA15_B

|___|

CD_ STA15_C

16. Play Therapy .................................................................................... |___|

CD_STA16_A

|___|

CD_ STA16_B

|___|

CD_ STA16_C

17. Art Therapy....................................................................................... |___|

CD_STA17_A

|___|

CD_ STA17_B

|___|

CD_ STA17_C

18. Group Counseling for Children of Addicts .......................................... |___|

CD_STA18_A

|___|

CD_ STA18_B

|___|

CD_ STA18_C

19. Attend AlaTot.................................................................................... |___|

CD_STA19_A

|___|

CD_ STA19_B

|___|

CD_ STA19_C

20. Attend AlaTeen................................................................................. |___|

CD_STA20_A

|___|

CD_ STA20_B

|___|

CD_ STA20_C

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

CD_STA21_A

|___|

CD_ STA21_B

|___|

CD_ STA21_C

22. Father-Child Parenting/Bonding Classes............................................ |___|

CD_STA22_A

|___|

CD_ STA22_B

|___|

CD_ STA22_C

23. Mother/Father/Child Counseling/Classes ........................................... |___|

CD_STA23_A

|___|

CD_ STA23_B

|___|

CD_ STA23_C

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

CD_STA24_A

|___|

CD_ STA24_B

|___|

CD_ STA24_C

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

CD_STA25_A

|___|

CD_ STA25_B

|___|

CD_ STA25_C

26. Special/Remedial Education (for learning disabled)............................ |___|

CD_STA26_A

|___|

CD_ STA26_B

|___|

CD_ STA26_C

27. Evidence of Aftercare Plan................................................................ |___|

CD_STA27_A

|___|

CD_ STA27_B

|___|

CD_ STA27_C

28. Established Socio-economic Support at State and Federal 

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

|___|

CD_STA28_A

|___|

CD_ STA28_B

|___|

CD_ STA28_C

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

CD_2006.00