Facilitator Weekly Progress Report
Consumers Name
Beginning Week Of:
-
Month
-
Day
Year
Date
End of Week:
-
Month
-
Day
Year
Date
Facilitator Name
Weekly contacts (1 Face-to-Face & 2 telephone contacts per week) Minimum Requirement
Contact 1 Date
/
Month
/
Day
Year
Date
Contact 1 Beginning Time
Hour Minutes
AM
PM
AM/PM Option
Contact 1 Ending Time
Hour Minutes
AM
PM
AM/PM Option
Contact 1 type:
Face-to-Face
Phone
Area of Discussion:
Is there any change in the consumer's medication?
Yes
No
If "yes" list changes:
Contact 2 Date
/
Month
/
Day
Year
Date
Contact 2 Beginning Time
Hour Minutes
AM
PM
AM/PM Option
Contact 2 Ending Time
Hour Minutes
AM
PM
AM/PM Option
Contact 2 Type
Face-to-Face
Phone
Area of Discussion
Is there any change in the consumer's medication?
Yes
No
If "yes" list changes:
Contact 3 Date
/
Month
/
Day
Year
Date
Contact 3 Beginning Time
Hour Minutes
AM
PM
AM/PM Option
Contact 3 Ending Time
Hour Minutes
AM
PM
AM/PM Option
Contact 3 Type
Face-to-Face
Phone
Area of Discussion
Is there any change in the consumer's medication?
Yes
No
If "yes" list changes:
Client signature
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Continue
Continue
Should be Empty: