Men's Case Manager Check In

Mens Case Manager / Participant

Check In/Goal Mapping
Participant Name:*
Case Manager doing check-in:*
House:*
Phase:*
Recommend Phasing Up?

YESNot at this time
Which Phase?
Date

MonthDayYear
12 Step Meeting Report:
Monday
Monday First 12 Step Meeting:
Monday First Meeting Time:
Monday Second 12 Step Meeting
Monday Second Meeting Time:
Monday Third 12 Step Meeting
Monday Third Meeting Time:
Monday 12 Step Meetings:
Tuesday
Tuesday First 12 Step Meeting:
Tuesday First Meeting Time:
Tuesday Second 12 Step Meeting
Tuesday Second Meeting Time:
Tuesday Third 12 Step Meeting
Tuesday Third Meeting Time:
Tuesday 12 Step Meetings:
Wednesday
Wednesday First 12 Step Meeting:
Wednesday First Meeting Time:
Wednesday Second 12 Step Meeting
Wednesday Second Meeting Time:
Wednesday Third 12 Step Meeting
Wednesday Third Meeting Time:
Wednesday Meetings:12 Step
Thursday
Thursday First 12 Step Meeting:
Thursday First Meeting Time:
Thursday Second 12 Step meeting
Thursday Second Meeting Time:
Thursday Third 12 Step Meeting
Thursday Third Meeting Time:
Thursday 12 Step Meetings:
Friday
Friday First 12 Step Meeting:
Friday First Meeting Time:
1st Meeting
Friday Second 12 Step Meeting
Friday Second Meeting Time:
Friday Third 12 Step Meeting
Friday Third Meeting Time:
Friday 12 Step Meetings:
Saturday
Saturday First 12 Step Meeting:
Saturday First Meeting Time:
Saturday Second 12 Step Meeting
Saturday Second Meeting Time:
Saturday Third 12 Step Meeting
Saturday Third Meeting Time:
Saturday 12 Step Meetings:
Sunday
Sunday First 12 Step Meeting:
Sunday First Meeting Time:
1st Meeting
Sunday Second 12 Step Meeting
Sunday Second Metting Time:
Sunday Third 12 Step Meeting
Sunday Third Meeting Time:
Sunday 12 Step Meetings:
Optional Meeting Notes:

Activity Report:
Monday
Monday Activity:
Monday Activity (2):
Monday Activity (3):
Tuesday
Tuesday Activity:
Tuesday Activity (2):
Tuesday Activity (3):
Wednesday
Wednesday Activity:
Wednesday Activity (2):
Wednesday Activity (3):
Thursday
Thursday Activity:
Thursday Activity (2):
Thursday Activity (3):
Friday
Friday Activity:
Friday Activity (2):
Friday Activity (3):
Saturday
Saturday Activity:
Saturday Activity (2):
Saturday Activity (3):
Sunday
Sunday Activity:
Sunday Activity (2):
Sunday Activity (3):
Optional Activity Notes

Medical/ Treatment report:
Counseling report:
When was your last Dorthea and/or Mental Health appts?
Sponsor report:*
Who is your sponsor, what is their number, and what step are you on?
Courts report:
Community service report:*
How many verified hours? How many hours are you required?
Financial/ food reports:
Does your participant have enough food?
Program fee report:*
How much has been paid, how much is owed etc.
Are you struggling with anything?
Strengths
First Strength
Second Strength
Third Strength
Excelling in what areas?
What participant/case manager wants Pastors Bill & Vicky to know about this program:

	NO	YES	In progress	N/A
Child Custody
Employment

	1-Not so good	2	3-moderate	4	5- Great
Health
Emotional
Spiritual

Mens Case Manager / Participant

12 Step Meeting Report:

Activity Report: