WEEKLY PROGRESS REPORT

Plesae complete the following fields by noon on the day of your weekly house meeting.

Client first name Client last name 

SOBRIETY DATE  Text field

Any changes to your cell phone number? Radio buttons

If Yes, provide new cell phone number. ONLY ANSWER IF YOUR NUMBER HAS CHANGED: Client phone

Do you have any community service hours that need to be completed?  Radio buttons

Did you complete any community service hours this week? Radio buttons

How many hours did you complete this week? Text field

How many total hours left to complete ?  Text field

Do you have any outstanding fines or restitution to be paid? Radio buttons

If Yes, what is the outstanding amount? Text field

Do you have outstanding cost of supervision to be paid? Radio buttons

If Yes, what is the outstanding amount? Text field

Do you have a curfew from your PO? Radio buttons

If Yes, what is your PO Curfew? Text field

What is your House Curfew? Text field

Have you missed curfew this week for any reason? Radio buttons

If you missed curfew, where were you, why did you miss curfew? Text field

Please initial to acknowledge that you can be discharged from the program if proof of after curfew work and/or meeting hours have not been provided: Initials Text field

Do you have anyone with whom you are NOT allowed to associate? Radio buttons

If Yes, Please list those person(s): Text field

Do you have any APPROVED House Associations outside of recovery work? Radio buttons

If Yes, please list: Text field

Do you have a job? Radio buttons

If YES, please provide your schedule (INCLUDE DAYS AND TIMES) for this coming week: Text field

If NO, Have you applied for any jobs this week? List where you have applied or explain why you haven't applied anywhere: Text field

Do you have a vehicle on property? Radio buttons

If Yes, have you turned in registration and insurance? If No Leave Blank. Radio buttons

What is your chore this week? Text field

Have you completed your chores this week? Radio buttons

Did you attend any classes, treatment, meetings or appointments this week? Radio buttons

List the classes/meetings/treatment including dates and times that you attended this week: Text field

Do you have classes, treatment, meetings or appointments NEXT week? Radio buttons

List the days and times for upcoming classes, meetings, treatment or appointments including dates and times: Text field

Have you had a relapse since our last meeting? Radio buttons

If Yes, provide the relapse date and substance used: Text field

Have you had any triggers this week? Radio buttons

If Yes, what happened, who were you with? Text field

Did you UA anywhere this week? Radio buttons

Did you Pass or Fail? Radio buttons

Provide Dates and Results of UAs taken: Text field

Any changes to prescriptions? Radio buttons Text field

Are you prescribed any medications that would show up on a UA? Radio buttons If so, please list: Text field

 

Any travel dates upcoming? Radio buttons

If traveling, remember to request a travel permit from your PO. Travel also needs to be approved by the house and a copy of travel permit must be provided.

Enter your program fee due date here: Text field

Reminder that The Nova Residence is a PROGRAM. We are NOT a landlord. The fees that are paid are PROGRAM FEES and NOT rent.  Note that there is a $5 per day late fee.  If program fees are 5 or more days past due, that is grounds for immediate discharge from the program. All billing questions should be directed to Bernie Tomei bernie@thenovaresidence.com or (408) 893-7939 Please initial to acknowledge. Initials Text field

Do you have an anticipated Move Out Date? Radio buttons

What is your transition plan/goal for getting into permanent housing? Text field

Use this space to provide any clarification on the answers above, additional information, feedback, success stories or concerns that you would like to address with us or that you would like us to address with the house. Text field

By signing below, I certify that the information provided above and true and correct: 

Signature: Signature Date: Date

Remember to bring any signed meeting verification forms and your Curfew Checklist to this week's meeting for staff review.

If you have any questions, please reach out to us by email at info@thenovaresidence.com

Thank you,

The Nova Residence