Date
-
Month
-
Day
Year
Date
Men's Participant Check-In
Name
*
First Name
Last Name
House
*
Faith Farm
Heart Change
Exodus
Montoya Manor
Hope Haven
What phase are you in?
*
Blackout
Phase I
Phase II
Phase III
Graduate
How many meetings did you attend this week?
*
Name of meeting?
*
When?
/
Month
/
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Name of second meeting?
*
When?
*
/
Month
/
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Name of third meeting?
*
When?
*
/
Month
/
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Names of other meetings?
Do you attend outpatient treatment?
YES
NO
Which program or facility?
XChange BHA
Columbia River Mental Health
Lifeline
Community Services NW
SeaMar
Real Life
Telecare
Other
Name of Facility or Program
How many days did you go this week?
*
Do you see a counselor or go to other treatment or classes?
*
YES
NO
Describe?
How many days did you go this week?
*
Case Manager:
*
Paul
Lance
Luz
PK
Enter Case Manager's Name
Any struggles with your Case Manager?
*
What was the message of Saturdays Church Service?
*
What are some ways you can apply that message to your life?
*
Do you have a sponsor?
YES
NO
Sponsor's name:
*
Sponsor's number:
-
Area Code
Phone Number
Did you meet with your sponsor?
*
YES
NO
Did you talk to your sponsor?
*
YES
NO
Why didn't you meet or talk with your sponsor?
What step are you on?
*
NOT LISTED
AA Step 1
AA Step 2
AA Step 3
AA Step 4
AA Step 5
AA Step 6
AA Step 7
AA Step 8
AA Step 9
AA Step 10
AA Step 11
AA Step 12
Power to Choose Step 1
Power to Choose Step 2
Power to Choose Step 3
Power to Choose Step 4
Power to Choose Step 5
Power to Choose Step 6
Power to Choose Step 7
Power to Choose Step 8
Power to Choose Step 9
Power to Choose Step 10
Power to Choose Step 11
Power to Choose Step 12
Spiritual Step 1
Spiritual Step 2
Spiritual Step 3
Spiritual Step 4
Spiritual Step 5
Spiritual Step 6
Spiritual Step 7
Spiritual Step 8
Spiritual Step 9
Spiritual Step 10
Spiritual Step 11
Spiritual Step 12
Codependency Step 1
Codependency Step 2
Codependency Step 3
Codependency Step 4
Codependency Step 5
Codependency Step 6
Codependency Step 7
Codependency Step 8
Codependency Step 9
Codependency Step 10
Codependency Step 11
Codependency Step 12
12 Step Christianity Step 1
12 Step Christianity Step 2
12 Step Christianity Step 3
12 Step Christianity Step 4
12 Step Christianity Step 5
12 Step Christianity Step 6
12 Step Christianity Step 7
12 Step Christianity Step 8
12 Step Christianity Step 9
12 Step Christianity Step 10
12 Step Christianity Step 11
12 Step Christianity Step 12
I am on this step:
How many hours of community service?
*
What is your required community service hours?
*
Are you working?
YES
NO
Where or for whom did you work?
How many hours did you work this week?
*
Number of applications turned in?
*
Where did you apply?
Rows
Company 1
Company 2
Company 3
Company 4
Company 5
Company 6
Company 7
Company 8
Are your program fees current?
*
YES
NO
Program Fee Balance:
*
Is there a plan to address the balance?
*
YES
NO
What is the payment plan:
*
I am struggling with:
*
I am feeling better about:
*
What I like about living here:
*
Is there anything you feel needs improving here?
*
Do you have an appointment made with Dorthea?
Yes
No
If so what date?
-
Month
-
Day
Year
Date
What Time?
Do you need an appointment with Dorothea?
Yes
No
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