Educational Support Recovery Group
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Service
Face to Face
Phone
Group Location
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
(THIS DOCUMENT IS NOT INDICATIVE OF ANY REFLECTIVE CLINICAL OPINION OR CLINICAL DIAGNOSIS )
Group Name
Notes
Content of encounter
Goals Addressed
Observations
Referral to other services
Number of participants
(If group session notes required for each client)
Participant Signature
Recovery Coach Signature
Recovery Coach Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: