Roots Client Weekly Update : Minnesota CarePartner

Client Weekly Update
Client Name

First NameLast Name
Primary Counselor*
Substance Use & Withdrawal Assessment- Dimension 1
Have you consumed any of the following substances since your last update?**

NoneAlcoholMarijuanaBenzodiazepinesHeroinOpiates/OpioidsMethamphetamineRitalin/Adderall/EtcCocaineMolly/MDMAInhalantsSalviaLSD/HallucinogensSynthetic CannabisBath Salts/CathinonesKratomSteroidsDXM/Cold MedsGHBMethadoneSuboxone/SubutexPseudoephedrineCaffeineNicotineOther OTC MedsOther Substance
Are you currently receiving medication assisted treatment?*

Not on MATOn MethadoneOn SuboxoneOther MATOther
What is your current dose?*
How long have you been at this dose?*
Please describe any withdrawal symptoms you may be experiencing examples include shaking, vomiting, fatigue, cold sweats, etc:*
Physical Health & Wellness- Dimension 2
Please rate how physically “well” you have felt this week:**

Great-1Good-2Just Ok-3Not Good-4Awful-5
Explain:**
Any new medical/health issues?**

YesNo
Describe:
Did you have any Medication changes this week?**

YesNo
What/When?
Any appointments this week?**

YesNo
What/When?**
Sleep Quality?**

Great-1Good-2Just OK-3Not the Best-4Awful-5Other
How many hours per night?**
ex. 0-4hrs, 5-8hrs, 9-12hrs
How many regular, quality meals do you eat on an average day?**

1234 or more
What are you doing for Physical Activity?*
ex. walking, yoga, running/jogging, biking, sports, swim, gym etc.
Emotional/Mental and Cognitive Wellness- Dimesion 3
Rate your overall mood this week:**

Great!-1Good!=2Just Ok-3Pretty Bad-4Awful-4
Have you experienced any of the following Mental Health Symptoms in the last week?

Increased AnxietyDepressed MoodDifficulty concentratingExcessive worringFatigueIsolationIrritabilityOther
Rate your overall stress level this week:**

Very LittleA LittleMediumToo Much!Extreme!
Biggest stressors this week:**
Have you had any thoughts of self-harm this week?**

NoYes
Have you acted on any thoughts?**

NoYes
Readiness for Change - Dimension 4
What was your biggest accomplishment this week?**
What is your primary motivation for being in recovery/treatment?**

My Own Goals/HealthProbation/CourtsChild ProtectionHousingFamily/PartnerSomething Else
What group did you enjoy the most?**

NutritionMental HealthPrimary CounselorGender Specific GroupMake-up Group
What is your main goal right now?**
Episode Use/Coping Skills/Stress Management- Dimension 5
What two coping skills have you used this week?

friendfamilyrecovery coachfact checkingself soothingself careTIPPDEARMANmindfulnesspeer supportasking for helprecreationexercisesticking to a routinecleaningcuddling with a petother
How confident have you felt in your recovery/sobriety?**

Extremely ConfidentVery ConfidentSomewhat ConfidentNot Very ConfidentNot at All Confident
Please identify any triggers that you’ve experienced this week:**

Select AllUsing FriendsFamily MembersPartners/SpousesBars/ClubsOld NeighborhoodsSeeing Drugs/AlcoholSocial SituationsCelebrationsDining OutMovies/TVSexual EncountersMoneyHolidaysAds/MarketingStressSadnessDepressionFrustration/AngerIrritabilityDishonestyLonelinessOverconfidenceGuilt/ShameSelf-LoathingDiscrimination/PrejudiceLegal IssuesNegative ThoughtsFear of FailureWanting to Feel HighWanting to Feel BetterCriminal Thrill-SeekingLonging for the Old LifestyleWanting to BelongOther:
Have you been having trouble with any of the following behavioral challenges?**

OvereatingRestricting FoodBinging/PurgingSexual BehaviorSpending/ShoppingGamblingVideo GamesRepetitive BehaviorsCompulsions/ObsessionsCutting/Self-HarmCompulsive CleaningExcessive ExercisingHair Pulling/Skin-PickingOther Compulsive BehaviorsNone of the Above
Recovery Enivronment - Dimension 6
Are you in a recovery residence?**

YesNo
Have you had any changes to your living environment and is your counselor aware?**

YesNo
How many supportive relationships do you currently have?**

15+10+5+A handfulNone
Who do you consider your primary support presently?**
How often do you connect with your support network?**

Daily2+ x/WeekWeeklyWhen NeededNot Often
How often do you attend mutual/recovery support groups?**

Daily2+ x/WeekWeeklyWhen NeededNot Often
Do you have a sponsor/recovery coach?**

YesNoWorking on it
How often do you talk to them?**
What are you doing for fun/recreation?**
How are things with your sober house leader/peers?**

GreatGoodOkNot the BestAwfulN/A
Do you have any probation/court/CPS meetings coming up?**

NoYesN/A
Details:**
Are you following all of your legal requirements?**

NoYesN/A
If it applies, how is work/school going for you?**

GreatGoodOkNot the BestAwfulN/A
Anything else you’d like us to know?
Email
Should be Empty: