Weekly Report

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* 1. Enter first and last name:

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* 2. Phase:

1

2

3

4

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

Yes

No

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

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

Yes

No

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* 5. 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:

Date & Result:

Date & Result:

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

Yes

No

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* 7. 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:

Date Completed, Number of Hours, & Location:

Date Completed, Number of Hours, & Location:

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

Session name and what you got from it?

Session name and what you got from it?

Session name and what you got from it?

Session name and what you got from it?

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* 10. 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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* 11. Short Term goals or plans:

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

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* 13. What do you plan on doing to support your recovery and/or goals this coming week?

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* 14. Provide details on your week, your struggles/challenges/successes, and do you need anything?

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* 15. Describe a coping skill or relapse prevention skill you used this week. Did it help?

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