[State of Iowa] DIAL Quarterly Report

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IBM Quarterly Report - Participant Form

Your Name:

Do you have a new address, phone number or email address you would like us to contact you at?

Indicate which quarter this report covers:

1st Quarter: January - March (due 4/20)

2nd Quarter: April - June (due 7/20)

3rd Quarter: July - September (due 10/20)

4th Quarter: October - December (due 1/20)

List of dates of appointments/sessions with ALL providers from this quarter?

Current Symptoms & Treatment:

Please provide an update on how you are progressing with your treatment goals. Successes? Barriers to making progress? Changes with symptoms?

Has there been a change in your treatment/diagnosis? If yes, please indicate the change.

Did you experience any suicidal ideations this past quarter?

Yes

Who is a part of your current support system and how have they supported you? Has there been any changes? Please explain.

Describe any successes and/or challenges in your personal life:

Describe any successes and/or challenges with your employment, co-workers, etc.:

Have any changes been made in your work status such as on call, hours, loss of staff, increase in duties, etc.? Please explain.

What are you doing to maintain your recovery when it comes to personal life & work demands? Please explain.

If it is part of your program requirement, are you attending self-help groups and/or meetings? What groups and/or meetings are you attending and how often? Pllease also explain how these are going for you in detail. (Indicate n/a if not applicable)

How would you describe your involvement in your meetings and/or groups? (Please indicate n/a if not applicable)

If you participate in AA/NA, what step are you currently on? (Please indicate n/a if not applicable)

If you have a sponsor, how often do you meet in person? How often do you talk to them? (Please indicate n/a if not applicable)

What explanation for any missed meetings, groups and/or appointments with your treatment team this quarter, if any?

Are you in compliance with the terms of your IPHP contract? Please explain.

Do you have any plans to travel during the quarter coming up? If yes, please provide details below.

Have you experienced a return to use during this quarter?

Yes

Do you have any questions for the IPHP staff?

Yes

Please describe how you feel your recovery/rehabilitation program is progressing, particularly making note of any barriers, events, changes, etc. that have assisted or posed any obstacles in your recovery:

Your Signature:

First Name

Last Name

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