Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Supported Employment

Client Outcomes—Quarterly Report Form

Client ID: _____________________	Reported by: _______________________
Date: _________________________	Quarter: ___________________________

Indicate the client's status during the past 3 months. Check all that apply:

Evidence-Based Practice	Eligible	Enrolled
Integrated Dual Disorders Treatment
Supported Employment
Assertive Community Treatment
Illness Management & Recovery
Family Psychoeducation

In the past 3 months, how many weeks has the client:

Held a competitive job?
Been homeless?
Been incarcerated?
Been hospitalized for psychiatric reasons?
Been hospitalized for substance use reasons?

What has been the client's stage of substance abuse treatment during the past 3 months? Circle one.

N/A

Engagement

Persuasion

Active treatment

Relapse prevention

What is the client's current living arrangement? Circle one.

1. Psychiatric hospital
2. Substance use hospitalization
3. General hospital psychiatric ward
4. Nursing home or IC-MH
5.Family care home
6. Lives with relatives (heavily dependent for personal care)
7.Group home

8. Boarding house
9. Lives with relatives (but is largely independent)
10. Supervised apartment program
11. Independent living
12. Other (specify)
13. Emergency shelter
14. Homeless

What is the client's current educational status? Circle one.

1. No educational participation
2. Avocational/educational involvement
3. Pre-educational explorations
4. Working on GED
5. Working on English as second language
6. Basic educational skills

7. Attending vocational school or apprenticeship, vocational program (CNA training) or attending high school
8. Attending college-1-6 hours
9. Attending college -7 or more hours
10. Other (specify)

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