Blue Ridge Circuit DAC
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DOCUMENTS AND FORMS
Case Management Online Check-in
Please complete and submit at least 24 hours before your scheduled case management appointment.
*
Indicates required field
Name
*
First
Last
[object Object]
Case Manager
*
Progress Assessment:
Please Answer the following questions.
Since we last spoke...
General Status
How many days have you been abstinent?
From your drug of choice?
*
From alcohol?
*
From other drugs?
*
Has anything happened that you think may increase your HIV risk?
*
No
Yes
Risk Factors: Situations that May Increase Your Risk for Relapse
1. Medical
Have you had any medical appointments?
*
No
Yes
Have you had any changes in prescribed medications?
*
No
Yes
Are you taking your medications as prescribed?
*
No
Yes
I am not taking any medications
Are you feeling well today?
*
No
Yes
2. Mood
How often have you felt depressed or like you had no interest in anything? (Answer: _______ times)
*
How long did it last? (Answer: ________ days)
*
3. Confidence
On a scale of 0 to 100, with 0 being not at all confident and 100 being completely confident, how confident are you that you can stay alcohol and drug free until our next call? (Answer: I'm ______% confident)
*
4. Cravings
How often have you had thoughts of using, even if you did not want to use? (Answer: I had cravings _________times last week.)
*
How strong were these thoughts - how much did those thoughts bother you or make you want to pick up?
*
Strong
Medium
Mild
No current cravings or thoughts of using
5. Triggers
How often were you in these situations you identified as your people, places, and things? (Answer: I was around my triggers situations ________times last week.)
*
How often did you have emotions or feelings that are triggers for use? (Answer: ________ times I had emotions that have been triggers for use.)
*
6. High-Risk Situations
How did you deal with the people, places, and things or internal triggers to use?
*
7. Sober Activities
How often have you done things with people who are abstinent from alcohol and drugs, or who don't have an alcohol/drug problem? (Answer: _____times I did something with people who do not use or are in recovery.)
*
(Answer: _____ times I made plans with people who do not drink or use drugs.)
*
8. Personal Goals
What steps have you taken toward your personal goals?
Goal 1:
*
Actions:
*
Goal 2:
*
Actions:
*
9. Meetings
How many community support meetings have you attended? (Answer: I attended _____ meetings last week.)
*
How often do you share? (Answer: I shared at _____ meetings last week.)
*
How often do you do service? (Answer: I helped out at _______ meetings last week.)
*
10. Sponsor
How often have you spoken to your sponsor? At meetings/not at meetings? On the phone or in person?
*
11. Financial
Has your employment changed since our last phone call?
*
No
Yes
How many hours per week are you working currently?
*
Have you submitted proof of income online?
*
No
Yes
Are you able to pay your bills or meet your financial obligations at this time?
*
No
Yes
12. Plan
High-risk situations between now and next call:
*
Plan for dealing with high-risk situations between now and next call:
*
My goals to work on between now and next call:
*
Submit
Home
OUR MISSION
WHAT DAC OFFERS
HOW TO APPLY
THE TEAM
STEERING COMMITTEE
GRADUATION
MORE
PAYMENT
>
MAKE A PAYMENT
SUBMIT PROOF OF PAYMENT
PROOF OF COMMUNITY SUPPORT MEETING
CASE MANAGEMENT CHECK-IN
>
CM GWEN GREEN
CM LAUREN SAPINSKI
CM CHRISTY HAMBY
CM HEATHER DUNCAN
PARTICIPANT REQUEST
>
CM GWEN GREEN
CM LAUREN SAPINSKI
CM CHRISTY HAMBY
CM HEATHER DUNCAN
MEDICATION REQUEST
PROOF OF EMPLOYMENT/INCOME
>
CM GWEN GREEN
CM LAUREN SAPINSKI
CM CHRISTY HAMBY
CM HEATHER DUNCAN
WORK SCHEDULE (AFTER CURFEW)
>
CM GWEN GREEN
CM LAUREN SAPINSKI
CM CHRISTY HAMBY
CM HEATHER DUNCAN
DOCUMENTS AND FORMS