Date
-
Month
-
Day
Year
Date
Women's Participant Check-In
Name
*
First Name
Last Name
How many 12 Step 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
15
30
45
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
Other meetings this last week?
Do you attend outpatient treatment?
YES
NO
Which program or facility?
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?
Who is your Case Manager:
*
No Case Manager
Kelly
What phase are you on?
*
Blackout
Phase I
Phase II
Phase III
Graduate
Any struggles with your peer coach?
*
What was the message from 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
Talk to your sponsor?
*
YES
NO
Why didn't you meet or talk with your sponsor?
*
What step are you on?
*
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
Graduate
Intensive Step 1
Intensive Step 2
Intensive Step 3
Intensive Step 4
Intensive Step 5
Intensive Step 6
Intensive Step 7
Intensive Step 8
Intensive Step 9
Intensive Step 10
Intensive Step 11
Intensive Step 12
OA Step 1
OA Step 2
OA Step 3
OA Step 4
OA Step 5
OA Step 6
OA Step 7
OA Step 8
OA Step 9
OA Step 10
OA Step 11
OA Step 12
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 job 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 may need improving?
*
Do you have an appointment with Dorthea?
Yes
No
If so what is the date?
-
Month
-
Day
Year
Date
What is the time?
Do You need an appointment with Dorothea?
yes
no
Allready have one set
Submit
Should be Empty: