Client Stat Sheet
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Client Info
Client #
Client Name
Program Date
MM
/
DD
/
YYYY
Housing (3 months Mark)
House Location
Miscellaneous Info
Benefit Status
Program $$ Status / Amount Due
# of Urinalysis/#of Positive
# of activity sheet turned in
Other: Counselor
IOP Information
Recovery Performance (1- Poor, 3- Good, 5-Great)
# of active IOP active days & # of make-up days
# of Excused IOP Attendance
# of Unexcused IOP Attendance
# of Self Help Mts (NA/AA) 90 meetings in 90 days
Housing Information
Housing Performance (1- Poor, 3- Good, 5-Great)
Last Chance Agreement Status
# of House Rule Violation(s)
# of Police Reports
# of Sign Incident Reports
# of Curfew Violation(s)
# of Chores Violation(s)
Other
Other
Other Information
Comments
Workforce
For more information,
OOH Training Department : 443.805.8927
OOH Main Office 1.855.9. OOHHOPE (1.855.966.4467)
PW@OrganiationOfHope.org
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