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First name *

Last name *

Date of Entry

Made Bed?

House Keeping?

Work, School, Job Search or Volunteer?

Clinical Services

12 Step Meeting: Fellowship? Where? When? Topic/Type?

Treatment Plan Work?

Exercise?

Follow Nutrition Plan?

Prayer or Meditation?

Met with Sponsor?

Medication Complaint?

Please be specific. One-word answers are not acceptable.

Which areas of your life and/or recovery have you improved upon this week, and how?

Which areas of your life and/or recovery are you struggling with or need to work on, and how?

Did you have any good experiences this week? If so, what?

Did you have any low experiences this week? If so, what?

Is there anything you need to discuss, or need help with?

What are the 3 or 4 goals that you want or need to accomplish this week?

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