Men's Participant Check-In

Date

MonthDayYear
Date
Men's Participant Check-In
Name*

First NameLast Name
House*
What phase are you in?*
How many meetings did you attend this week?*
Name of meeting?*
When?

MonthDayYear
DateHourMinutesAM/PM Option
Name of second meeting?*
Other meetings this last week?
When?*

MonthDayYear
DateHourMinutesAM/PM Option
Do you attend outpatient treatment?*

YESNO
Which program or facility?

XChange BHAColumbia River Mental HealthLifelineCommunity Services NWSeaMarReal LifeTelecareOther
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?*

YESNO
Describe?
How many days did you go this week?*
Case Manager:*
Enter Case Manager's Name
Did you meet with your Case Manager?*

YESNO
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?

YESNO
Sponsor's name:*
Sponsor's number:

Area CodePhone Number
Did you meet with your sponsor?*

YESNO
Did you talk to your sponsor?*

YESNO
Why didn't you meet or talk with your sponsor?
What step are you on?*
I am on this step:
How many hours of community service?*
What is your required community service hours?*
Are you working?

YESNO
Where or for whom did you work?
How many hours did you work this week?*
Number of applications turned in?*