CM LORI HAGAMAN

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

Case Manager *

Progress Assessment:

Please Answer the following questions.

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? *

Risk Factors: Situations that May Increase Your Risk for Relapse

1. Medical

Have you had any medical appointments? *

Have you had any changes in prescribed medications? *

Are you taking your medications as prescribed? *

Are you feeling well today? *

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? *

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? *

How many hours per week are you working currently? *

Have you submitted proof of income online? *

Are you able to pay your bills or meet your financial obligations at this time? *

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

CASE MANAGEMENT CHECK-IN ONLINE

Case Management Online Check-in

Progress Assessment: