Section 1 of 1 in this document

Quarterly Report - Interstate Monitoring

Indicate which quarter this report covers:

1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

List current requirements with your primary monitoring contract (i.e. therapy, group, meetings, drug screens

Current Symptoms & Treatment Goals:

What, if any, barriers have you met in working toward your goals?

What is your most current support system?

Describe any challenges & successes in your personal life:

Describe any challenges & successes with your employment, co-workers, hours, etc.:

Has there been a change in your work status such as on call, hours, loss of staff, increase in duties, changes in duties, etc.?

How many days a month do you currently practice in Iowa?

Are you able to maintain your mental health, sobriety, etc. in the face of personal life & work demands?

If applicable, how many self-help meetings are you attending each week?

If applicable, how often do you meet with your sponsor?

Yes

Yes

First Name

Last Name

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