Dental, Pharmacy, Professional Licensing Quarterly Report - Aftercare Provider

Quarterly Report - Aftercare Provider

Participant's Name:

Aftercare Provider's Name & Credentials:

Aftercare Provider's Contact Information:

Indicate which quarter this report covers:

1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

Dates of Group Sessions:

Date of Individual Sessions:

Current Treatment Goals:

Has progress been demonstrated toward their goals?

Yes

Does the participant actively participate in group discussion?

Yes

Does the participant give and receive feedback appropriately?

Yes

Does the participant appear motivated and ask for help?

Yes

Does the participant have insight into their condition?

Yes

Does the participant attend self-help meetings weekly?

Yes

Did the participant experience a return to use during this quarter?

Yes

Please provide an explanation for your responses above:

Which self-help meetings does the participant attend? AA, NA, Celebrate Recovery, SMART, or other? How often?

Do you recommend any changes to the participant's individual and/or group requirements, including frequency of self-help meetings, need for re-evaluation, etc.? If yes, please use the space provided to explain.

Do you recommend a change in frequency of sessions? If yes, please use the provided space to explain.

Are the proper supports/requirements in place for monitoring and treatment to promote success? Please explain.

Have you communicated with the participant's monitoring health care provider this quarter?

Yes

Based on your knowledge, is the participant adherent with their IPHP contract?

Yes

Would you like IPHP staff to contact you?

Yes

Any further Comments, Questions or Concerns?

Your Signature:

First Name

Last Name

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