Weekly Report Survey

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* 1. Enter first and last name:

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* 2. Phase:

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* 3. Which option below best fits your average hours of sleep for this last week?

Needs Improvement (around 4 hours or less per night)

Decent (around 5 hours per night)

Good (around 7 hours per night)

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* 4. Have you used any substances in this last reporting week? Remember: RIGOROUS HONESTY

Yes

If you answered yes, list the date/s you used and what substance/s you used.

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* 5. Did you report for drug testing this week?

Yes

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* 6. If you reported for drug testing, please provide the date and whether you think the results will be negative or positive. If positive, what substance? (Response not required if none taken).

Date & Result:

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* 7. Did you complete any Community Service or Volunteer work this week?

Yes

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* 8. If you completed CSW, please enter the dates completed, number of hours completed, and location (i.e. van, PAWS, community garden, etc.).

Date Completed, Number of Hours, & Location:

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* 9. Please list the date, treatment session name and whether your attendance is a yes or no. (Example: 5/22 Motivation to Change Yes, etc.) If you missed any groups, please explain why.

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* 10. Regarding the treatment sessions you attended this week, what did you get out of each session?

Session name and what you got from it?

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* 11. Did you interact with Law Enforcement, your Physician, or did you take any medications this week? If yes, please explain. Reminder: Always provide copies of new prescriptions.

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* 12. What are your personal goals for the next week or two?

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* 13. Long Term goals, plans, education or career ambitions?

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* 14. What was the highlight of your week?

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* 15. Share a challenge or struggle from this week and what you did to try to overcome it.

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* 16. What is your stress level on a scale of 1-10 (1 is lowest)? Describe what recovery skills (coping, self-care, or relapse prevention) you used this week.

Weekly Report

Question Title

* 1. Enter first and last name:

Question Title

* 2. Phase:

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* 3. Which option below best fits your average hours of sleep for this last week?

Question Title

* 4. Have you used any substances in this last reporting week? Remember: RIGOROUS HONESTY

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* 5. Did you report for drug testing this week?

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* 6. If you reported for drug testing, please provide the date and whether you think the results will be negative or positive. If positive, what substance? (Response not required if none taken).

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* 7. Did you complete any Community Service or Volunteer work this week?

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* 8. If you completed CSW, please enter the dates completed, number of hours completed, and location (i.e. van, PAWS, community garden, etc.).

Question Title

* 9. Please list the date, treatment session name and whether your attendance is a yes or no. (Example: 5/22 Motivation to Change Yes, etc.) If you missed any groups, please explain why.

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* 10. Regarding the treatment sessions you attended this week, what did you get out of each session?

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* 11. Did you interact with Law Enforcement, your Physician, or did you take any medications this week? If yes, please explain. Reminder: Always provide copies of new prescriptions.

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* 12. What are your personal goals for the next week or two?

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* 13. Long Term goals, plans, education or career ambitions?

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* 14. What was the highlight of your week?

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* 15. Share a challenge or struggle from this week and what you did to try to overcome it.

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* 16. What is your stress level on a scale of 1-10 (1 is lowest)? Describe what recovery skills (coping, self-care, or relapse prevention) you used this week.

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* 17. Who was helpful to you this week and why? Could you have asked for help or support and chose not to?