MTFC INSPIRE DATA
Discharge Follow-up
______ Worksheet complete
______Data entered in INSPIRE
Additional information about how to answer the questions can be found
in the INSPIRE Screen Guide for Clinical Users.
Highlighted items are required for current Performance Measure calculations.
Case ID: ______________ Youth’s First and Last Name:_______________________________________
Interview Date: _____/______/______
Interview conducted by:
Phone
In Person
Mail
Unable to Contact
Refused Interview
Interview Respondent:
Youth
Mother
Father
Foster parent
Stepmother
Stepfather
Adoptive parent
Legal guardian
Non-parent relative
Other (specify: ___________________________________)
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MTFC INSPIRE DATA
Discharge Follow-up
Youth’s living Situation:
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: _________________________________________)
Youth’s work status:
Does not work
Volunteer
Part-time
Full-time
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MTFC INSPIRE DATA
Discharge Follow-up
COUNTY & LEGAL INVOLVEMENT
Is youth currently on probation?
Yes
No
Has youth been discharged from C&Y?
Yes
No
Has youth been charged with any offense or probation violation since discharge/last interview?
Yes (complete chart on next page)
No (skip to page 5)
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MTFC INSPIRE DATA
Discharge Follow-up
Since discharge/last interview, what type(s) of offense and/or probation violations has the youth been
charged with? What was the court outcome?
OFFENSES
Check all that
apply in the
column to the left.
COURT OUTCOME
Select one for each offense committed
Dismissed
Closed
Etc.*
Awaiting
disposition
or diag.
evaluation
Probation/
Community
Service/
Fines
Court
ordered to
treatment
or program
Court
ordered to
placement
or
detention
Transferred
to criminal
(adult)
court
Sexual offense
Prostitution
D&A crime
Harassment
Theft
Vandalism
Fire setting
Forgery
Weapon
Homicide
Truancy
Robbery
Assault on a
person
Stalking
Other,
Specify:
*Includes: Dismissed, Not Substantiated, Complaint Withdrawn, Counseled, Warned, and Case Closed
**If reason is “Other,” specify reason.
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Other
**
MTFC INSPIRE DATA
Discharge Follow-up
BEHAVIOR ISSUES
Please select all of the behavior issues that the youth has experienced since discharge/last interview.
For each behavior selected, indicate the frequency and whether youth was placed due to that behavior.
For each behavior selected, has
Has the following
For each behavior selected,
youth been placed for behavior
behavior been a
please indicate the frequency
that occurred since discharge?
problem since
Rarely
Sometimes
Often
Very often
Yes,
Yes,
discharge/last
(1-2 times in (3-4 times in (more than
(almost
No
family-like
congregate
past month) past month)
once/ week) daily)
interview?
therapeutic placement*
Mark all that apply in
column to the left.
Runaway
placement*
Firesetting/arson
Cruelty to animals
Alcohol use
Drug use
Tobacco use
Verbal aggression
Depression
Parent/child
conflict
Suicidal ideation
Suicide attempt
Self-harm/
mutilation
Physical
aggression
Gang
involvement
Cult involvement
Pregnant
Sibling conflict
Other, Specify:
*If youth was placed for behavior issues, indicate type(s) of care:
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MTFC INSPIRE DATA
Discharge Follow-up
Family-like therapeutic placement:
Specialized or therapeutic foster care
CRR Host Home placement
Congregate placement:
Emergency shelter
Group home
Juvenile detention
Correctional center, Jail
Residential Center (non-D&A)
Residential or inpatient drug and alcohol
Inpatient psychiatric hospital
EDUCATION
What is the youth’s current educational status? (as of this year if currently in school and as of end of
previous year if currently out of school for summer vacation)
Quit School
Work training /vocational program in place of High School
Still in school (Grade: ____)
GED
High School Diploma
If youth is still in school or in a work training/vocation program, has the youth experienced any
issues in school since discharge/last interview?
Yes (complete chart below)
No (stop here)
Select all of the behavior issues that the youth has been experienced since discharge/last interview.
For items selected, indicate the frequency.
Rarely (1-2 times
Sometimes (3-4
Often (more
Very often
Select all that apply in
in
past
month)
times
in
past
than
once
a
(almost daily)
column to the left.
month)
Truancy
Suspended
Expelled
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week)