Client Weekly Update "*" indicates required fields Step 1 of 10 10% Client Name* First Last Program Elite Recovery for Men Elite EmPower for Women Elite Affirm LGBTQIA Extended Outpatient Elite Advantage Elite Engage Which Advantage residence?Grand HouseFeronia HousePrimary Counselor*Select your Primary Counselor HereAshley DankBreanna DedekerBrian WhitsonBrittany MoselleChoice Pickins NewstromHanna SchmitzJackelyn PikeJill TraynorKarla SelnessKaren JohnsonMax JamesMike O'BrienNicole FriendPeter HansonRichard McCulloughSara GreenbaumTerrance McDonaldOtherPrimary Group*Argyle Advantage GroupArlington GroupAshland GroupDale GroupEdgerton GroupEngage Virtual GroupHamline GroupLexington GroupPortland GroupRivera Affirm GroupSnelling GroupSt. Clair GroupSummit GroupVandalia GroupVictoria GroupWabasha – Men's EOP M & WMen's EOP – T & TH CONTACT DETAILSHas any of your contact information below changed since last week?* Yes No This is my first time filling this out What has changed?*Check all that apply Address Phone Number Email Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current Phone Number:*Current Email:* TREATMENT DETAILSCurrent Treatment Stage* Primary IOP Step-Down IOP Extended OP Attendance Days* Monday Tuesday Wednesday Thursday Friday Living Environment:*Sober LivingIndependentOtherWho you are living with?*Sober House Name:*Where are you living?*Advantage Clients: Please skip to next page. SUBSTANCE USE & WITHDRAWAL ASSESSMENTWhat is your last date of substance use?* MM slash DD slash YYYY What did you use on that date?*Have you consumed any of the following substances since your last update?*Check all that apply 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 None of the above 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 & WELLNESSPlease 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?*Have you been eating regular, quality meals?* Yes No What's getting in the way?Any medical/dental appointments this week?* Yes No What/When?Please list any new physical health meds or medication changes:*If applicable, do you take your medications as directed?* Yes No Not Applicable Do you get regular physical exercise?* Yes No Describe:* EMOTIONAL, BEHAVIORAL & MENTAL HEALTHWhat 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 Please talk to a staff member as soon as possible!Rate your overall mood this week:* Great Good Just Ok Pretty Bad Awful Rate your overall stress level this week:* Very little stress A little stress Medium stress Too much stress Extreme stress Biggest stressors this week:*Name two coping skills you’ve used this week:*Do you take your psychiatric meds as prescribed?* Yes No Not Applicable Any mental health appointments this week?* Yes No What/When?*What were some significant events for you this week?* RECOVERY MOTIVATION AND PARTICIPATIONWhat is your primary motivation for being in recovery/treatment?* My Own Goals/Health Probation/Courts Child Protection Housing Family/Partner Something Else How exited are you about your recovery this week?* Very Excited Pretty Excited Neutral Tired or Burned Out Not at all excited Please tell us how excited you’ve been to do the following activities this week:Treatment Engagement*On a scale of “very excited” to “not at all excited,” how are you feeling about attending and sharing in group this week? Very Excited Pretty Excited Neutral Tired or Burned Out Not at all Excited 5 out of 5 Other Treatment Appointments:*On a scale of “very excited” to “not at all excited,” how are you feeling about attending other treatment appointments such as Individual Counseling, Therapy, Medication Management and/or Peer Support meetings? Very Excited Pretty Excited Neutral Tired or Burned Out Not at all Excited Other Recovery Activities:*On a scale of “very excited” to “not at all excited,” how are you feeling about attending outside sober support meetings, sober house meetings, and/or probation meetings? Very Excited Pretty Excited Neutral Tired or Burned Out Not at all Excited What Elite Recovery group did you enjoy most this week?*What is your main recovery goal right now?* RELAPSE PREVENTION/RECOVERY MANAGEMENTHow confident have you felt in your recovery this week?* Extremely confident Very confident Somewhat confident Not very confident Not at all confident Please identify any triggers that you’ve experienced this week:*Check all that apply 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 None of the above Have you been having trouble with any of the following behavioral challenges?*Check all that apply 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 What coping skills did you use this week to prevent relapse?*Who or what was the most influential in your recovery this week?* RECOVERY ENVIRONMENT, RELATIONSHIPS & SUPPORT NETWORKAre you in a romantic relationship?* No Yes If so, How long?How many supportive relationships do you currently have?* 15 or more 10 or more 5 or more 1 or more None Who do you consider your primary support at present?*How often do you connect with your support network?* Daily 2 or more times a week Weekly When Needed Not Often How often do you attend recovery support groups (AA/NA/DHARMA/etc.)* Daily 2 or more times a week Weekly When Needed Not Often Do you have a sponsor, recovery coach, or mentor?* Yes No Working on it How often do you talk to them?* Daily 2+ x/Week Weekly Monthly When Needed N/A 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 is your relationship with the individuals you live with?* Great Good Ok Not the Best Awful N/A Do you have any legal involvement?* No Yes Pending Do you have any probation/court/CPS meetings coming up?* No Yes Details:*Are you following all of your legal requirements?* No Yes N/A Any new charges/arrests?* No Yes If it applies, how is work/school going for you?* Great Good Ok Not the Best Awful N/A PROGRAM EXPERIENCEPlease 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?*Please rate your experience with Elite's Health Promotion Services this week.*This includes Dietitian/nutritionist and/or Registered Nurse. 0 = Poor 10 = Excellent 0 1 2 3 4 5 6 7 8 9 10 N/A – No Services Provided Comments for Health Promotions Team:What do you like most about Elite Recovery?*Least?*What would make the program better?*Do you have any other needs for our treatment coordinators or peer recovery specialists?* No Yes – Peer Recovery Specialist Yes – Treatment Coordinator Peer Recovery Support Needs:*Treatment Coordinator Needs:*
