60 Day Review-Women
Name
*
First Name
Last Name
Client ID #
Today's Date
*
-
Month
-
Day
Year
Date
Intake Date
*
-
Month
-
Day
Year
Date
Facility
*
12th Street A
12 Street B
St Alberts
Canyon Meadows
Cameo Court
N. Truckee
Program
Domestic Violence/Sex Trafficking program? HPN Insurance
HPN Short Term Bed?
HPN Long Term Bed?
SS Short Term Bed?
SS Long Term Bed
SS Respite
Renown Respite
Criminal Justice Project
Other
Medicaid Provider
*
HPN
Silver Summit
Anthem
Molina
Other
MEASURES OF SUCCESS
Measures of Success Score
Resident must achieve a minimum of 80 points to move on to the next phase of the program. If resident is not achieving stated goals, please discuss with your team to determine next steps to ensure goals are achieved.
1. PRSS
*
Yes
No
Attend scheduled meetings with PRSS as scheduled
2. Self-Help
*
Yes
No
Attend self-help groups
3. Home Group
*
Yes
No
Verified Home Group
4. Sponsor
*
Yes
No
Verified Sponsor
5. Spiritual Services
*
Yes
No
Attend spiritual services
6. Family Reunification
*
Yes
No
N/A
Continue family reunification
7. Savings Account
*
Yes
No
N/A
Open savings account (NA only applies if client is unemployed, employed clients are required to open a savings acct)
8. Medical Needs
*
Yes
No
N/A
Schedule and/or attend medical appointments
9. Mental Health Needs
*
Yes
No
N/A
Schedule and/or attend mental health appointments
10. D/A Evaluation
*
Yes
No
N/A
Completed drug/alcohol evaluation
11. Mental Health Evaluation
*
Yes
No
N/A
Completed mental health evaluation if required
12. WoW Group
*
Yes
No
N/A
Attend Women of Worth groups (only applies to female clients)
13. MRT Group
*
Yes
No
N/A
Attend MRT groups
14. Budgeting
*
Yes
No
Completed budget
15. Goal Setting
*
Yes
No
Completed goal setting activities
16. Job Connect
*
Yes
No
N/A
Continued interaction with Job Connect
17. Employment
*
Yes
No
N/A
Employed
Was there in increase in socioeconomic status?
Yes
No
N/A
18. Education
*
Yes
No
Has High School Diploma or equivalency
19. Enrolled in GED Course
*
Yes
No
N/A
Enrolled in High School Equivalency courses (clients without a High School Diploma or GED are required to enroll in GED courses)
20. Continuing Education
*
Yes
No
Enrolled in TMCC or other continuing education courses
21. Program Rules (Life Changes)
*
Positive
Average
Poor
Adherence to program rules and expectations
22. Rules (CJ professionals)
*
Yes
No
N/A
Adherence to rules and expectations of criminal justice mandates
23. Transition Plan
*
Yes
No
Completed initial transition plan, including budgeting and identification of safe housing
24. Clean/Sober
*
Yes
No
Abstinence from drugs/alcohol or other addictive disorders
25. Interactions
*
Positive
Average
Poor
Positive interaction with house mates and program staff
26. Compliance
*
No
1
2
3+
Received warnings of non-compliance (please check the number of warnings client has received)
Did resident leave the program during her 60-day stay?
Yes - self discharge
Yes - to higher level of care
No - continued stay
Extension
Yes
No
Will resident need an extension of her 90-day stay?
Recommendation for continued residency.
*
Yes
No
Explain the reasons for your recommendation. Be specific.
*
Comments
*
General overview of clients progress past 30-days
Staff Name
*
First Name
Last Name
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