Client Outcome Measure

(COM-Y)

Name*

First Last

Date of Birth*

Date of Final Session*

Today's Date*

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

Forms – Client Outcome Measure A

Client Outcome Measure

(COM-Y)

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.

Please answer the following questions using the number from the scale above. Remember – answer according to how much has changed since you began counseling.