Client Weekly Update
Client Name
First Name
Last Name
Primary Counselor
*
Please Select
Select your counselor here
Jay Gold
Mikare Michira
Rachael Cavegn
Rashad Hameed
Rosmarie Dauth
Victoria Reesman
Other
Substance Use & Withdrawal Assessment
Have you consumed any of the following substances since your last update?*
*
None
Alcohol
Marijuana
Benzodiazepines
Heroin
Opiates/Opioids
Methamphetamine
Ritalin/Adderall/Etc
Cocaine
Molly/MDMA
Inhalants
Salvia
LSD/Hallucinogens
Synthetic Cannabis
Bath Salts/Cathinones
Kratom
Steroids
DXM/Cold Meds
GHB
Methadone
Suboxone/Subutex
Pseudoephedrine
Caffeine
Nicotine
Other OTC Meds
Other Substance
Are you currently receiving medication assisted treatment?
*
Not on MAT
On Methadone
On Suboxone
Other MAT
Other
What is your current dose?
*
How long have you been at this dose?
*
Please describe any withdrawal symptoms you may be experiencing:
*
Physical Health & Wellness
Please rate how physically “well” you have felt this week:*
*
Great
Good
Just Ok
Not Good
Awful
Explain:*
*
Any new medical/health issues?*
*
Yes
No
Describe:
Sleep Quality?*
*
Great
Good
Just OK
Not the Best
Awful
How many hours per night?*
*
How many regular, quality meals do you eat on an average day?*
*
1
2
3
4 or more
Do you want to meet with a nutritionist?*
*
yes
no
Any appointments this week?*
*
Yes
No
What/When?
Did you have any Medication changes this week?*
*
Yes
No
What/When?*
*
What are you doing for Physical Activity?
*
What was your biggest accomplishment this week?*
*
Have you had any thoughts of self-harm this week?*
*
No
Yes
Have you acted on any thoughts?*
*
No
Yes
Rate your overall mood this week:*
*
Great!
Good!
Just Ok
Pretty Bad
Awful
Rate your overall stress level this week:*
*
Very Little
A Little
Medium
Too Much!
Extreme!
Biggest stressors this week:*
*
What two coping skills have you used this week?
friend
family
recovery coach
fact checking
self soothing
self care
TIPP
DEARMAN
mindfulness
peer support
asking for help
recreation
exercise
sticking to a routine
cleaning
cuddling with a pet
other
What group did you enjoy the most?*
*
Nutrition
Mental Health
Primary Counselor
Gender Specific Group
Make-up Group
What is your primary motivation for being in recovery/treatment?*
*
My Own Goals/Health
Probation/Courts
Child Protection
Housing
Family/Partner
Something Else
Treatment Group:*
*
Very!
Excited!
So-So
Ugh!
Noooo!
Other Treatment Appointments:*
*
Very!
Excited!
So-So
Ugh!
Noooo!
Other Recovery Activities:*
*
Very!
Excited!
So-So
Ugh!
Noooo!
What is your main goal right now?*
*
How confident have you felt in your recovery/sobriety?*
*
Extremely Confident
Very Confident
Somewhat Confident
Not Very Confident
Not at All Confident
Please identify any triggers that you’ve experienced this week:*
*
Select All
Using Friends
Family Members
Partners/Spouses
Bars/Clubs
Old Neighborhoods
Seeing Drugs/Alcohol
Social Situations
Celebrations
Dining Out
Movies/TV
Sexual Encounters
Money
Holidays
Ads/Marketing
Stress
Sadness
Depression
Frustration/Anger
Irritability
Dishonesty
Loneliness
Overconfidence
Guilt/Shame
Self-Loathing
Discrimination/Prejudice
Legal Issues
Negative Thoughts
Fear of Failure
Wanting to Feel High
Wanting to Feel Better
Criminal Thrill-Seeking
Longing for the Old Lifestyle
Wanting to Belong
Other:
Have you been having trouble with any of the following behavioral challenges?*
*
Overeating
Restricting Food
Binging/Purging
Sexual Behavior
Spending/Shopping
Gambling
Video Games
Repetitive Behaviors
Compulsions/Obsessions
Cutting/Self-Harm
Compulsive Cleaning
Excessive Exercising
Hair Pulling/Skin-Picking
Other Compulsive Behaviors
None of the Above
Are you in a recovery residence?*
*
Yes
No
Have you had any changes to your living environment and is your counselor aware?*
*
Yes
No
How many supportive relationships do you currently have?*
*
15+
10+
5+
A handful
None
Who do you consider your primary support presently?*
*
How often do you call/text/chat with your support network?*
*
Daily
2+ x/Week
Weekly
When Needed
Not Often
How often do you spend face-to-face time with your support network?*
*
Daily
2+ x/Week
Weekly
When Needed
Not Often
How often do you attend mutual/recovery support groups?*
*
Daily
2+ x/Week
Weekly
When Needed
Not Often
Do you have a sponsor/recovery coach?*
*
Yes
No
Working on it
How often do you talk to them?*
*
Rate how “connected” you feel to others around you:*
*
Very
Quite
Just Ok
Not Very
Not at all
What are you doing for fun/recreation?*
*
How are things with your sober house leader/peers?*
*
Great
Good
Ok
Not the Best
Awful
N/A
Do you have any probation/court/CPS meetings coming up?*
*
No
Yes
N/A
Details:*
*
Are you following all of your legal requirements?*
*
No
Yes
N/A
If it applies, how is work/school going for you?*
*
Great
Good
Ok
Not the Best
Awful
N/A
Please rate your relationship with your counselor:*
*
The Best
Pretty Good
Just Ok
Not the Greatest
Terrible
What can they do to improve the relationship?*
*
What can you do?*
*
What do you like most/least about this program?*
*
What would make the program better?*
*
Anything else you’d like us to know?
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