Individuals Served Monthly Report Form

Name Of Client: *

Date of Review:

Apartment Number: *

Email *

Phone Number: *

Are you currently in treatment? If so, where? *

Have you attended any support group meetings during the past thirty days for example, NA, AA, Celebrate Recovery, etc? *

Do you have any legal issues current or pending? *

Are you on active probation or parole? *

Do you have a stable social support system for your recovery? *

Are you employed? *

If you are not employed, are you looking for work? *

Have you participated in any community activities during the past thirty days? *

If not, what community activities are you interested in participating in? *

What are your long-term goals that will aid in your stability and transition from this housing program? *

What are your short-term goals that will aid in your stability and transition from this housing program? *

Do you have any diagnosed mental or medical health conditions? If so, what are they? *

Do you currently take medications for any diagnosed mental or medical health conditions? *

Do you have any current needs? *

Are there any repairs or damage to report in your apartment? *

Do you understand that this is temporary housing and if funding should end, you will have to have a plan in place to continue paying rent? *

What are your grocery needs for the month? Please note that you will be contacted prior to your order being submitted. *

What are your hygiene needs for the month? Please note that you will be contacted prior to your order being submitted. *

What are your clothing needs for the month? Please note that you will be contacted prior to your order being submitted. *

How has this program helped you focus on your recovery journey? *

Are there any other issues to be noted? (copy) *

Get In Touch With Us

Office Number (336) 268-6469

Fax Number (678) 782-3373

1-888-STARTNOW (Contact Someone Immediately)

Our services are also available via Telehealth including LIVE Zoom sessions.

LOCATIONS

Nygil M. Cullins Semi-Independent Recovery Housing

283 Grant Avenue Macon, GA 31202

Changing Phases Behavior Support Inc.

3655 Canton Rd Suite 201 Marietta GA 30066 |678. 903. 5197 | 888.574.2737

Nygil Cullins Recovery Treatment Center

2101 Tebeau St Waycross, GA 31501