BROTHERS AND KEEPERS CORPORATION
LEAH’S PLACE: 30 DAY PROGRESS REPORT (Due Every 15th)
Youth Name
*
First Name
Last Name
Participant ID Number
*
Date
*
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Month
-
Day
Year
Date Picker Icon
Location
*
LEAH’S PLACE
Attitude
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Positive Attitude
Gets along with peers
Completes Chores
Follows Directions
Uses Profanity
Leadership Skills
School
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Always On Time
Completes Homework
On Track to Pass
Needs Tutoring
Independent Living Skills
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Life Skills Improved
Social Skills Developed
Cooking Skills Improved
Budget Skills Improved
Nice Clothing Appearance
Great Hygiene
Family
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Positive Interaction with Family Members
Working towards family unification
Vision/Hearing/Physical
Excellent Condition
Satisfied
Needs Improvement
Poor Condition
Medical Assistance Needed
Vision
Hearing
Dental
Physical Condition
Able to participate in Sports and/or Strenuous Activities
Yes
No
Sports
Running
Weight Lifting
Work
Currently Job Searching
Currently Working
Always on time to work
Managing finances properly
Not interested in working
Extracurricular Activities
ATHLETICS
ROTC
BAND
COMMUNITY SERVICE
CHURCH
DRAMA
CREATIVE ARTS PROGRAM
Other
Additional Comments/Notes
*
Case Manager Name
*
First Name
Last Name
Case Manager E-mail
*
Staff Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
BKC Staff Signature
*
Submit
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