Oregon Community Programs

OCP Outcomes Questionnaire


Today’s Date:

Child First Name:

Child Last Name:

First & Last Name of person filling out this form:

Relationship to Child:


SECTION A: Education/School

  1. Is the child attending school right now? 
  2. If no, why isn’t the child in school right now?

     (If it’s summer, answer about the most recent school year

  3. What grade is the child in now (or last grade, if it is summer)?

  4. What’s the name of the child’s current school?

  5. What type of school does the child attend? If summer, last school attended. Please select one:

    Has the child EVER received any of the following Education Related Services?
  6. Special Education (resource room, class aid, etc)

    IF YES, currently in service?

     

  7. Chapter I/Title 1

    IF YES, currently in service?

     

  8. IEP (Individualized Educational Plan)

    IF YES, currently in service?

     

  9. Services for disabilities (504 Plan)

    IF YES, currently in service?

     

  10. In-school counseling

    IF YES, currently in service?

     

  11. After school tutoring

    IF YES, currently in service?

  12. Currently, how is the child’s school attendance (or “Last Month Attended” if summer)?

  13. Currently, how is the child’s behavior at school (or “Last Month Attended” if summer)?

  14. How is the child doing with schoolwork (or “Last Month Attended” if summer)? 

     

  15. Has the child ever: (SELECT ALL THAT APPLY)

          a. Been suspended from school

          b. Been expelled from school

          c. Been in trouble with teachers, parents have been contacted

          d. Been in trouble with the principal, parents have been contacted

          e. Been in other significant trouble at school

          f. None of the above

          g. Don’t Know


SECTION B. Mental Health History

  1. Has the child ever had a psychiatric evaluation?
  2. Has a doctor or mental health professional ever determined that the child has a mental health diagnosis?

     

  3. Please list Diagnoses: 

a)  

b)  

c)  

d)  

  1. Has the child ever been prescribed medication for “emotional,” “nervous,” “hyperactive behavior,” “depression,” “anxiety,” or other problems?
  1. Is the child currently taking any of these medications?
  2. How many mental health medications is the child currently taking?
Please tell us about the child’s current mental health medications:

a) Medication #1 name

b) What is the medication prescribed for?

c) Child’s age when 1st prescribed this medication?

a) Medication #2 name

b) What is the medication prescribed for?

c) Child’s age when 1st prescribed this medication?

a) Medication #3 name

b) What is the medication prescribed for?

c) Child’s age when 1st prescribed this medication?

a) Medication #4 name

b) What is the medication prescribed for?

c) Child’s age when 1st prescribed this medication?  

  1. Has the child ever spent time in an Inpatient Mental Health Hospital or facility?
  2. How many times?
  3. Start date of most recent stay:  
  4. For the most recent stay – Total # days spent as an Inpatient?

SECTION C. Foster Home Placement

  1. Has the child ever been placed in foster care?

     

  2. Is the child currently in foster care?
  3. If yes, Number of days in the current foster home?
  4. Was the child placed with any siblings in foster care?
  5. While in foster care, did the child have contact with one or more sibling(s) at least once a month?
  6. How old was the child when first placed in foster care?  
  7. How many foster home placements has the child had? (# of transitions between foster homes)
  8. What is the total amount of time spent in all foster care?

SECTION D. Involvement With Criminal Justice

  1. Has the child ever been arrested?

     

  2. How many times has the child been arrested?
  3. Has the child spent time in lockup/juvenile detention?

     

  4. How many days has the child spent in lockup/juvenile detention?

SECTION E. Volunteering/Working (For clients 14 or older ONLY)

Check all that apply

  1. Has the youth:

     

 

(Parent/Guardian Phone Number)

 

(Date)

 

Leave this empty:

Oregon Community Programs https://www.oregoncommunityprograms.org
Signature Certificate
Document name: OCP Outcomes Questionnaire
Unique Document ID: bc17fc9a41ae6160b48d9ea45c25753eb73dc7bf
Timestamp Audit
March 25, 2020 2:06 pm PDTOCP Outcomes Questionnaire Uploaded by Mindi Brock - mindib@oregoncp.org IP 10.0.1.85
March 25, 2020 4:22 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 25, 2020 4:59 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 10:27 am PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 1:18 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85
March 26, 2020 1:31 pm PDTIntake Coordinator - hazeld@oregoncp.org added by Mindi Brock - mindib@oregoncp.org as a CC'd Recipient Ip: 10.0.1.85