Clark County Treatment Court Web Report Form

TREATMENT COURT WEB REPORT FORM

Please fill in the form completely every time you report.

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

This form needs to be completed and submitted the week of your hearing on Tuesday by 6pm.

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 Clean Date

Court Clean date

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

Completed any required community service / program activity or prior court response?

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?

Positive Sobriety Report

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.