Recovery Coaching Encounter
Participant's Name
*
First Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Service
*
Face to face
Facetime/Zoom/Skype
Phone
Time In
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
Time Out
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
Transportation to:
# Miles
Notes:
Content of encounter
Goals Addressed:
Observations:
Referral to other services:
Coach Signature
Coach Name
First Name
Last Name
Submit
Should be Empty: