Skip to content
About
Programs & Services
Get Involved
Careers
Urgent Crisis Center
Patient Forms
Patient Portal
Donate
Phone:
860-437-4550
Search
Close Search
About
Programs & Services
Menu
Client Outcome Measure-Youth
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