Monthly Residents Report

Your name:*

First NameLast Name

Date

Please answer all of the questions on this survey to the best of your ability, and keep in mind the answers you are providing should represent the previous calender month. If a question does not apply to you please put a "0" as your answer.

Did you phase up in the last month?*

YESNO

Congratulations!! What phase are you in now?*

How many times last month have you been given a ride by someone in our program?*

Did you receive any type of housing support like HEN or ATR etc.? *

Did anyone in our program provide childcare for you (if yes how many times)?*

how many times did someone in our program help you with employment, job leads, or references?*

How many times did you attend relapse prevention classes like IOP etc?*

How many times did you go to family or marriage counseling in the last month?*

How many meetings did you go to last month?*

How many times did you attend advocacy skills training or leadership development classes like our housing team meetings or peer coach meetings? *

How many life skills would you say that you gained or improved?*

How many parent education classes did you attend?*

How many days would you say you had Spiritual support?*

Did you have help making medical appointments?*

Did you go to any counseling outside of our ministry i.e. mental health or Dorthea?*

How many children are you working towards obtaining custody of?*

Are you on probation, parole, or DOC?*

How many bill or fines did you have help paying?*

Monthly Participant Report