MTFC INSPIRE DATA

Discharge Follow-up

______Worksheet complete______Data entered in INSPIRE

Additional information about how to answer the questions can be found

in the INSPIRE Screen Guide for Clinical Users.

Highlighted items are required for current Performance Measure calculations.

Case ID: ______Youth’s First and Last Name:______

Interview Date: _____/______/______

Interview conducted by:

Phone

In Person

Mail

Unable to Contact

Refused Interview

Interview Respondent:

Youth

Mother

Father

Foster parent

Stepmother

Stepfather

Adoptive parent

Legal guardian

Non-parent relative

Other (specify: ______)

Youth’s living Situation:

2 Biological Parents

Biological Mother

Biological Father

Home of a Relative

Adoptive Home

Home of a Family Friend

Independent Living by Self

Independent Living with Friend

Supervised Independent Living

Foster Care

Specialized Foster Care

Therapeutic Foster Care

Residential Job Corps / Vocational Center

Group Home

Emergency Shelter

Residential Facility

Medical Hospital

Drug & Alcohol Rehabilitation

Inpatient in Psychiatric Hospital

Juvenile Detention Center / Youth Correctional Center

Jail

Homeless with Family

Homeless without Family

Runaway

Kinship Care

CRR Host Home

Other (specify: ______)

Youth’s work status:

Does not work

Volunteer

Part-time

Full-time

COUNTY & LEGAL INVOLVEMENT

Is youth currently on probation?

Yes

No

Has youth been discharged from C&Y?

Yes

No

Has youth been charged with any offense or probation violation since discharge/last interview?

Yes (complete chart on next page)

No (skip to page 5)

Since discharge/last interview, what type(s) of offense and/or probation violations has the youth been charged with? What was the court outcome?

OFFENSES
Check all that apply in the column to the left. / COURT OUTCOME
Select one for each offense committed
Dismissed
Closed
Etc.* / Awaiting disposition or diag. evaluation / Probation/
Community
Service/
Fines / Court ordered to treatment or program / Court ordered to placement or detention / Transferred to criminal (adult) court / Other
**
Sexual offense
Prostitution
D&A crime
Harassment
Theft
Vandalism
Fire setting
Forgery
Weapon
Homicide
Truancy
Robbery
Assault on a
person
Stalking
Other, Specify:

*Includes: Dismissed, Not Substantiated, Complaint Withdrawn, Counseled, Warned, and Case Closed

**If reason is “Other,” specify reason.

BEHAVIOR ISSUES

Please select all of the behavior issues that the youth has experienced since discharge/last interview. For each behavior selected, indicate the frequency and whether youth was placed due to that behavior.

Has the following behavior been a problem since discharge/last interview?
Mark all that apply in column to the left. / For each behavior selected,
please indicate the frequency / For each behavior selected, has youth been placed for behavior
that occurred since discharge?
Rarely
(1-2 times in past month) / Sometimes
(3-4 times in past month) / Often
(more than once/ week) / Very often
(almost daily) / No / Yes,
family-like therapeutic
placement* / Yes, congregate placement*
Runaway
Firesetting/arson
Cruelty to animals
Alcohol use
Drug use
Tobacco use
Verbal aggression
Depression
Parent/child conflict
Suicidal ideation
Suicide attempt
Self-harm/ mutilation
Physical aggression
Gang involvement
Cult involvement
Pregnant
Sibling conflict
Other, Specify:

*If youth was placed for behavior issues, indicate type(s) of care:

Family-like therapeutic placement:

Specialized or therapeutic foster care

CRR Host Home placement

Congregate placement:

Emergency shelter

Group home

Juvenile detention

Correctional center, Jail

Residential Center (non-D&A)

Residential or inpatient drug and alcohol

Inpatient psychiatric hospital

EDUCATION

What is the youth’s current educational status? (as of this year if currently in school and as of end of previous year if currently out of school for summer vacation)

Quit School

Work training /vocational programin place of High School

Still in school (Grade: ____)

GED

High School Diploma

If youth is still in school or in a work training/vocation program, has the youth experienced any issues in school since discharge/last interview?

Yes (complete chart below)

No (stop here)

Select all of the behavior issues that the youth has been experienced since discharge/last interview.

For items selected, indicate the frequency.

Select all that apply in column to the left. / Rarely (1-2 times in past month) / Sometimes (3-4 times in past month) / Often (more than once a week) / Very often (almost daily)
Truancy
Suspended
Expelled

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Rev. 7/14/11