Nccfw/dvc Abuser Treatment Program Quarterly Statistical Report Form
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NCCFW/DVC Abuser Treatment Program
Quarterly Statistical Report
AGENCY:
___________________________________________________________
PROGRAM NAME: _____________________________________________________
*COUNTY SERVED: ____________________________________________________
* Provide a separate form for each county served
Person completing this form
: ____________________________________________________
REPORTING Quarter (check one) Year: 20________
□ April – June (due July 15
th
□ October – December (due Jan. 15
th
)
)
□ July – September (due Oct. 15
□ January – March (due April 15
th
th
)
)
A. R
O
I
EFERRAL
UTCOME
NFORMATION
1. Referrals received this quarter, counted by referring source
Male Clients
Female Clients
Spanish Speaking
____ Criminal Court
____ Criminal Court
____ Criminal Court
____ Civil Court
____ Civil Court
____ Civil Court
____ DSS
____ DSS
____ DSS
____ Mental Health
____ Mental Health
____ Mental Health
____ Substance Abuse
____ Substance Abuse
____ Substance Abuse
____ Self-Referral
____ Self-Referral
____ Self-Referral
____ Probation/Parole Initiated
____ Probation/Parole Initiated
____ Probation/Parole Initiated
____ Total # referred
____ Total # referred
____ Total # referred
2. All referrals assessed and enrolled in group, counted by referring source
(Include in
this count all referrals accepted, even if the group has not yet begun. Count Hispanic clients separately only if you
provide Spanish only groups)
Male Clients
Female Clients
Spanish Only Group Enrollees
____ Criminal Court
____ Criminal Court
M____ F____ Criminal Court
____ Civil Court
____ Civil Court
M____ F____ Civil Court
____ DSS
____ DSS
M____ F____ DSS
____ Mental Health
____ Mental Health
M____ F____ Mental Health
____ Substance Abuse
____ Substance Abuse
M____ F____ Substance Abuse
____ Self-Referral
____ Self-Referral
M____ F____ Self-referral
____ Probation/Parole Initiated
____ Probation/Parole Initiated
M____ F____ Probation/Parole
____ Total # accepted
____ Total # accepted
M____ F____ Total # Accepted
3. All referrals not enrolled, listed by referring source
(
Include in this count all no-shows for a
scheduled intake, failure to respond to your program information, as well as those not appropriate for group)
Male Clients
Female Clients
Spanish Speaking Only
____ Criminal Court
____ Criminal Court
M ____ F____ Criminal Court
____ Civil Court
____ Civil Court
M____ F ____ Civil Court
____ DSS
____ DSS
M____ F ____ DSS
____ Mental Health
____ Mental Health
M____ F ____ Mental Health
____ Substance Abuse
____ Substance Abuse
M____ F ____ Substance Abuse
____ Self-Referral
____ Self-Referral
M ____ F ____ Self-referral
____ Probation/Parole Initiated
____ Probation/Parole Initiated
M____ F____ Probation/Parole In
____ Total # not enrolled
____ Total # not enrolled
M____ F____ Total not enrolled
NOTE:
Total # not enrolled in question #3, plus total # enrolled in question #2 , should equal the totals referred in question #1
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