Clark County Treatment Court Web Report Form

TREATMENT COURT WEB REPORT FORM

Please fill in the form completely every time you report. This form needs to be completed and submitted no earlier than 48 hours prior to court, but no later than 24 hours prior to court.

For assistance with this form or if you have trouble submitting it, please call Julie Anderson at (564) 397-5175 or email Julie.anderson@clark.wa.gov during business hours.

Please Note: You must provide a valid email address below to complete this form.

Participant Information

Select Court:

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 a recovery/supported living house?

Since your last report, have you...

Yes

Started, stopped, changed or made progress in school?

Yes

Started, stopped, or changed jobs?

Yes

Obtained a valid driver’s license?

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?

Positive Sobriety Report

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

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.