Dental, Pharmacy, Professional Licensing Quarterly Report - Participant Form

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

2nd Quarter

3rd Quarter

4th Quarter

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

Current Symptoms & Treatment:

Are you having difficulty working on these goals? Any changes in symptoms? Please explain.

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

What is your current support system? Has there been any changes? Please explain and list your current support systems.

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

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

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

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

If it is part of your program requirement, are you attending self help groups? What type of meetings do you attend and how often? (Please indicate n/a if not applicable)

How would you describe your involvement in your meetings? (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)

Explanation for any missed meetings and/or appointments with your treatment team this quarter:

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

Do you have any plans to travel during this quarter coming up?

Yes

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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