Women's Participant Check-In

Date

MonthDayYear
Date
Women's Participant Check-In
Name*

First NameLast Name
House*
How many 12 Step meetings did you attend this week?*
Name of meeting?*
When?*

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

MonthDayYear
DateHourMinutesAM/PM Option
Other meetings this last week?
Do you attend outpatient treatment?

YESNO
Which program or facility?

Columbia 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?
Who is your Case Manager:*
Did you meet with your peer coach?*

YESNO
What phase are you on?*
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?*

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

Area CodePhone Number
Did you meet with your sponsor?*

YESNO
Talk to your sponsor?*

YESNO
Why didn't you meet or talk with your sponsor?*
What step are you on?*
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 job applications turned in?*