Client Outcome Measure (COM-Y)Name* First Last Date of Birth* MM slash DD slash YYYY Date of Final Session* MM slash DD slash YYYY Today's Date* MM slash DD slash YYYY Instructions:Please help us understand what has changed or not since counseling began . Some of the questions are about you and some are about your family. Please use this scale to answer the questions below. 5 – Very much better Most all of the things you or your family tried to change were successful. Things are very much better. 4 – A lot better Many but not all of the things you or your family tried to change were successful. Things are a lot better. 3 – Some better Some of the things you or your family tried to change were successful. Things are somewhat better. 2 – Little better Few of the things you or your family tried to change were successful. Things are a little better. 1 – No Change The things you or your family tried to change are no different. 0 – Things are worse The things you or your family tried to change are worse. N/A Not Applicable This was not an issue when counseling began and is not an issue now.Please answer the following questions using the number from the scale above. Remember – answer according to how much has changed since you began counseling.1. In general, how much has the family changed since you began counseling?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse 2. How much has the family changed its communication skills?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Chnage 0 – Things are worse N/A Not Applicable 3. How much has your behavior changed?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse 4. How much have your caregiver(s) changed their parenting skills?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse N/A Not Applicable 5. How much have your caregiver(s) changed their ability to supervise you?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse N/A Applicable 6. How much change has occurred in the family conflict level?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse N/A Not Applicable Please answer the following questions about change in your behavior SINCE counseling began. If the behavior was not a reason why you were referred to counseling, it is ok to use non-applicable. Use the same scale as above. 7. How much did your illegal behavior change?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse N/A Not Applicable 8. How much did your runaway behavior change?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse N/A Not Applicable 9. How much did your school attendance change?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse N/A Not Applicable 10. How much did your school performance (e.g. grades, behavior) change?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse N/A Not Applicable 11. How much did your alcohol use change?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse N/A Not Applicable 12. How much did your drug use change?* 5 – Very much better 4 – A lot better 3 – Some better 2 – Little better 1 – No Change 0 – Things are worse N/A Not Applicable
