MTFC INSPIRE DATA
Discharge
______ Worksheet complete
______Data entered in INSPIRE
Case ID: _______________ First and Last Name:______________________________________
Additional information about how to answer the questions can be found
in the INSPIRE Therapist Screen Guide.
Discharge Date: ____/____/____
Was this discharge an administrative withdrawal?
Yes
No
If Yes (it was an administrative withdrawal), indicate reason below:
M.A. funding ceased
Family/youth moved out of service area
Placement for criminal offenses that occurred prior to MTFC enrollment
Other (specify reason: ________________________________________)
OUTCOMES
Did the youth achieve the goals on his/her treatment plan?
Yes
No
Did the youth move successfully through the 3 levels of the point-and-level system?
Yes
No
Was the youth discharged to a less restrictive placement (i.e., a successful outcome as defined
by MTFC for certification purposes)?
Yes
No
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MTFC INSPIRE DATA
Discharge
If you answered “No” to any of the three outcome items above, indicate the reason treatment
was unsuccessful:
Youth – No engagement in point system
Family – No engagement in treatment
Violation of probation
Runaway
Referred to a higher level of care
Lack of progress on treatment goals
Other
STOP HERE IF YOUTH WAS ADMINISTRATIVELY DISCHARGED
Has the youth’s school attendance improved?
Worse
No change
Improved
Has the youth’s school performance improved?
Worse
No change
Improved
Was the youth satisfied with his/her experience in the MTFC program?
Yes
No
Was the parent/caregiver satisfied with his/her experience in the MTFC program?
Yes
No
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MTFC INSPIRE DATA
Discharge
SITUATION AT DISCHARGE
Continued systems involved at the time of discharge (select all that apply):
Children & Youth
JPO
Special Education Services
o
Circle all that apply: Learning Support / Emotional Support / Alternative Education
Formal Mental Health Services
o
Circle all that apply: Residential / Partial / After School Treatment Program / FBMHS
MT,BSC,TSS / Other In-Home Treatment / Outpatient Therapy / Med Mgt.
Informal Natural Supports: Involvement in specific community activities/programs
Other (specify:___________________________________________________________)
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MTFC INSPIRE DATA
Discharge
Living Situation at discharge:
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: _________________________________________)
Discharge family structure:
Female caregiver
Male caregiver
Children (How many? ____)
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MTFC INSPIRE DATA
Discharge
Other Adult (specify relationship to youth: ______________________)
AFTERCARE RECOMMENDATIONS
Which drug & alcohol treatment is recommended at discharge?
No treatment recommended
Outpatient treatment
Intensive outpatient program
Partial program
Non-hospital residential
Inpatient or detoxification
Other (specify: _____________________________________________)
Mental health services recommended at time of discharge (select all that apply):
No treatment
MH case management
Lower-level care (select all that apply)
Medication Management
TSS
BSC
MT
Outpatient Therapy
Family-Based Mental Health Services
Other In-Home or Community-Based Services (other than MT, TSS, BSC & FBMHS)
Therapeutic afterschool program, school-based behavioral health program, or other centerbased group treatment program not listed elsewhere
Partial hospitalization
CRR Host Home with Treatment
Higher Levels of Care (select all that apply)
Inpatient psychiatric hospitalization
Residential treatment facility funded by M.A. (do not include residential placement
funded by Juvenile Justice or Child Welfare)
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