CM-YA Discharge Form

MM slash DD slash YYYY
Completion Status(Required)
Discharge Reason(Required)
Was client satisfied with experience in treatment?(Required)
Was parent / caregiver satisfied with their experience in treatment?(Required)
Did client demonstrate improvement in school / work attendance?(Required)
Did client demonstrate improvement in school / work performance?(Required)
Client had no new criminal offenses during treatment.(Required)
Client was involved in prosocial activities at discharge.(Required)
Caregiver demonstrated improved monitoring and supervision.(Required)
Evidence of reduced family conflict(Required)
Client was drug-free at discharge.(Required)
Did you provide drug screens?(Required)

Review Intake Form


Primary Race(Required)

Secondary Race - If Biracial Select One

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MM slash DD slash YYYY
Would this youth have been placed out of home if they were not accepted to participate in this program?(Required)
Primary Referral Source(Required)

Risk Factors - Check All That Apply(Required)
Primary Substance Used(Required)

Previous Treatment - Check All That Apply(Required)
Living Arrangement(Required)