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?*
When?*

MonthDayYear
DateHourMinutesAM/PM Option
Name of third meeting?*
When?*

MonthDayYear
DateHourMinutesAM/PM Option
Names of other meetings?
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?*