Follow Up Form

Admin Only

12345
Date*

MonthDayYear
Date
First Name*
Last Name*
Full Name
Date of Birth

MonthDayYear
Date
Age*
Address (If any changes)

Street Address

Street Address Line 2

CityState

Zip Code
Phone #*
if no phone number, please enter all 0's. Thank you
Email*
example@example.com
Resources/ Services Participated In:*

Employment AssistanceVocational/ Trade ServicesTransportation ServicesCommunity ServiceHygiene BackpackClothing AssistanceMentorship ProgramEducational ResourcesPeer Recovery CoachingHousing AssistancePersonal Protective Equipment (P.P.E.)Snap/ Medicaid Registration AssistanceS.E.E.D Program
Additional Resources Requested

Employment AssistanceVocational/ Trade ServicesTransportation ServicesCommunity ServiceHygiene BackpackClothing AssistanceMentorship ProgramEducational ResourcesPeer Recovery CoachingHousing AssistancePersonal Protective Equipment (P.P.E.)Snap/ Medicaid Registration AssistanceS.E.E.D Program
Mental Health Level:*

12345678910
Where are you currently in your sobriety?
How are you feeling today?*
How is employment going?*
What is your goal for the week?*
What can you do to help achieve your goal?*
What is your affirmation/ emotional support for the week?*
How have our services helped you?*
Additional comments, questions or concerns:
ADMIN USE ONLY

Please do not touch this section unless a member of The NXT Chapter staff. Thank you
Physical Wellness: (1 being not good at all - 10 being perfect)

12345678910Didn't see in person
Contact, Reschedule or Services No Longer Required:

Contact (If you talked directly to the client)Reschedule (Please put reasoning in additional comments)Services No Longer Requested (Explain in additional comments)
Additional Comments
Staff Member
Name of staff member that took care of client
Next Follow Up Date

MonthDayYear
Date
Signature of Staff Member

Clear
Date

MonthDayYear
Date
Should be Empty:

ADMIN USE ONLY