0 - National Criminal Justice Reference Service

COUNSELOR RATING OF CLIENT
PLEASE COMPLETE ALL INFORMATION BELOW:
INSTITUTION (CIRCLE ONE):
TYPE OF PROGRAM (CIRCLE ONE):
1 = CRESSON 1= EDUCATION
2 = GRATERFORD 4 = "TINGDON 2=OU"ATIENTTREA"T
3 = HOUTZDALE 5 = WAYMART 3 = T"EUl'IC COMMUNTIY
LAST NAME:
FJRSTNAME:
INMATE #:...... TODAY'S DATE: ......
MO DAY YEAR
HOW MANY CONSECUTIVE MONTHS HAVE YOU BEEN IN THIS PROGRAM? (CIRCLE ONE):
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 21 25+
A . CLIENT ATTRIBUTES: Circle the answer that shows how much you agree or disagree with each
item based on your interactions with this client .
1 . Easy to talk to .........................................
2 . Warm & caring .......................................
3 . Honest & sincere .....................................
4 . Cooperative .............................................
5 . Responsible .............................................
6 . Hostile or aggressive ...............................
7 . Depressed ...............................................
8 . Impulsive ................................................
9 . Nervous or anxious .................................
10 . Self-confident ..........................................
11 . Manipulative ...........................................
12 . Freely expresses wishes ...........................
13 . Motivated to recovery .............................
14 . Consistently keeps session
appointments ...................................
15 . Is liked by other clients ............................
16 . Participates in group discussions .............
17 . Thinks clearly ..........................................
18 . Pays attention ..........................................
19 . Clearly expresses thoughts/feelings ..........
20 . Reviews problems logically .....................
21 . Has good memory & recall ......................
22 . In denial about problems .........................
23 . Easily distracted ......................................
24 . Follows through on commhments ............
25 . Is liked by staff ........................................
DISAGREE NOT AGREE
STRONGLY ........... SURE ..........STRONGLY
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This document is a research report submitted to the U.S. Department of Justice. This report has not
been published by the Department. Opinions or points of view expressed are those of the author(s)
and do not necessarily reflect the official position or policies of the U.S. Department of Justice.