Form Center

2. First Name*
3. Last Name*
4. Current Age:*
6. Today's Date*
   Today's Date
7. Last Use Date:*
   Last Use Date:
8. Program Start Date:*
   Program Start Date:
9. Expected Graduation Date:*
   Expected Graduation Date:
11. Where are you currently residing?*

    1. Matt Talbot House
    2. Curtis Center
    3. Sober Living
    4. St. Monica's
    5. Independent Living
    6. Other
12. Do you have Post Release Supervision after Sentence Conversion*

    1. Yes
    2. No
    3. Unknown
13. Please list the name of a family member that is a positive support and their relationship to you. *
15. Were you late or did you miss any days of work this month? *

    1. Yes
    2. No
    3. Not currently employed
16. Why did you not meet all your employment requirements this month? *
17. What have you done this month to improve on goals related to your employment or gaining employment?*
19. Are you taking your prescription medication as prescribed and have enough medication prior to needing a refill?*

    1. Yes
    2. No
    3. I am not on any prescription medications
20. Please describe any concerns you have with your medications? *
22. Were you late or did you miss any treatment sessions this month? *

    1. Yes
    2. No
23. How many and why did you not attend all your treatment appointments on time this month? *
25. Please describe the progress you are making in treatment.*
27. Did you meet with your sponsor in person each week this month?*

    1. Yes
    2. No
    3. I do not have a sponsor?
28. Please list the step you are on and the progress you have made on the step this month.
30. Why did you not meet with your sponsor each week this month?
31. Please describe what you have done this month to obtain a sponsor.
33. Did you attend all your required community support meetings this month? *

    1. Yes
    2. No
34. How many and why did you not attend all your community support meetings this month?*
36. Are you currently enrolled in MRT? *

    1. Yes
    2. No
37. Please list what step you are on and list one thing you learned from the previous step you completed.*
38. Please list any other classes you attended this month.*
40. Are you following a budget that has been approved by Community Corrections?*

    1. Yes
    2. No
41. What needs to be done for you to follow your budget? *
43. Please list the balances of your checking and savings accounts as well as child support.*
45. Please describe the progress you are making toward financial stability or financial savings.*
47. What is one thing that went well this month?*
48. What areas in your program do you need to improve on?*
50. Please check all items that you have concerns with or need help with.*

    1. Medical/Dental
    2. Vision/Hearing
    3. Medications
    4. Disability
    5. Transportation
    6. Financial

    1. Food/Clothing/Hygiene Products
    2. Prosocial Activities/Positive Peers
    3. Relationships/Parenting
    4. Other
    5. None
51. Please detail items that you have concerns with or need help with.
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field