Nursing Quarterly Report - Interstate Monitoring

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?

Do you have plans to move your primary practice or residence to Iowa? If yes, please use the space provided to explain.

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?

Are you in compliance with your health program that serves as your primary monitor? If no, please explain why in space provided.

Yes

Any requests of the IPHP staff or committee to consider? If yes, please explain in space provided.

Would you like IPHP staff to contact you?

Yes

Your Signature:

First Name

Last Name

Choose how to sign

Draw Type