Clark County Treatment Court Web Report Form

TREATMENT COURT WEB REPORT FORM

Please fill in the form completely every time you report.

If you are in Drug Court, this form needs to be completed and submitted the week of your court hearing between Monday and Wednesday by NOON.

If you are in DOSA Drug Court this form needs to be completed and submitted the week of your court hearing between Monday and Wednesday by 6pm.

If you are in Family Treatment Court, this form needs to be completed and submitted the week of your hearing between Friday and Sunday before your next Family Treatment Court hearing.

For assistance with this form or if you have trouble submitting it, please call Paula Deans (564) 397-2168.

Please Note: In order to receive a confirmation of your submission, you must provide a valid email address below.

Participant Information

Event Number

First Name

Middle Name

Last Name

Cell Phone Number

Alternate Phone Number

Email Address

Personal Sobriety Date

Court Documented Clean Date

Yes

Has your address changed since your last report?

Yes

Is your home an Oxford/supported living house?

Yes

Do you have any special requests?

Since your last report, have you...

Yes

Started, stopped, changed or made progress in school?

Yes

Started, stopped, or changed jobs?

Yes

Used alcohol, drugs, or other mind/mood altering substances not prescribed by a doctor?

Yes

Had a medical or dental appointment?

Yes

Had contact with law enforcement?

Yes

Completed any required community service?

Yes

Started or Changed Treatment Schedule?

Yes

Missed any UA’s?

Yes

Missed any treatment sessions (groups, 1x1s, MH, medications, etc.)?

Yes

Missed any prosocial events / meetings?

Yes

Missed any other court / program activity?

Yes

Change in your visitation schedule with children?

Yes

Are you in Mental Health Treatment?

Positive Sobriety Report

List 1 strength / skill that you have.

Describe one good thing that has happened since your last report.

List 1 goal you are working on and some steps you’ve taken to achieve this goal.

Comments or Suggestions

Do you have any comments, suggestions, barriers you’d like us to know about. Feel free to tell us what incentive/reward would be helpful for YOU as well as what suggestion sanction/response should be considered.