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ABOUT US
- MEET THE STAFF
SERVICES
- FAQ’s
FORMS
MEDIA
- TNR RECOVERY STORIES
- PRESS
CAREERS
CONTACT
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Home » CLIENT STATUS REVIEW

Client Status Review

Client Status Review
Type Of CSR - Staff Only
- Initial
- 90-135 Day Follow-Up
- Discharge
Administered By - Staff Only
First Last
Date - Staff Only
Month
Day
Year
Client Name*
First Last
Date*
Month
Day
Year
Are you completing this survey for? (Please check one)*
- I filled this out by myself (age 12 and older)
- I filled this out for a child/youth (Under age 12)
- Someone helped me fill this out
What best describes the reason you came in for services today? (Select all that apply)*
- I decided on my own
- I was encouraged by others (like family, friends, etc.)
- I was required to come (including court order, Office of Children’s Services, etc.)
Health and Quality of Life
1. How many days during the past 30 days was your physical health (including physical illness and/or injury) not good?*
Please enter a number from 1 to 30.
2. How many days during the past 30 days was your mental health (including depression and/or problems with emotions, behavior, or thinking) not good?*
Please enter a number from 0 to 30.
3. How many days during the past 30 days did poor physical or mental health keep you from doing your usual activities, such as taking care of yourself, work, or recreation?*
Please enter a number from 0 to 30.
4. How many days during the past 30 days have you had thoughts about suicide or hurting yourself?*
Please enter a number from 0 to 30.
5. In the past 30 days, how many times have you used emergency medical services such as the hospital, emergency room, or emergency medical technicians/health aides?*
Please enter a number from 0 to 30.
6. In the past 30 days, have you had an intimate partner slap, punch, shove, kick, choke, hurt, or threaten you?*
- Yes
- No
Substance Abuse
7. How many days during the past 30 days have you had at least one alcoholic beverage?*
Please enter a number from 0 to 30.
8. How many days during the past 30 days have you had 4 or more alcoholic beverages?*
Please enter a number from 0 to 30.
9. How many days during the past 30 days have you used marijuana or illegal drugs (including medications not as prescribed or directed)?*
Please enter a number from 0 to 30.
Legal Involvement
10. In the past 30 days, have you had any, legal involvement (legalcharges, courtappearance, arrests,probation or parole)*
- Yes
- No
11. In the past 30 days, how many times have you been arrested?*
Please enter a number from 0 to 30.
12. In the past 12 months, how many times have you been arrested?*
Please enter a number from 0 to 30.
Health Behavior
13. How many days during the past 30 days have you smoked cigarettes, pipes, or cigars AND/OR used chewing tobacco, snuff, or snus?*
Please enter a number from 0 to 30.
14. How many days during the past 30 days have you smoked 20 or more cigarettes per day?*
Please enter a number from 0 to 30.
15. How many days during the past 7 days did you participate in any physical activities or exercise such as running, sports (basketball, baseball etc.), swimming, bicycling or walking for exercise?*
Please enter a number from 0 to 30.
16. During the past 7 days, how many times did you drink 100% fruit juice or eat fruit?*
Please enter a number from 0 to 30.
17. During the past 7 days, how many times did you eat vegetables?*
Please enter a number from 0 to 30.
18. Please answer each question by marking the space that best describes how you feel about each item.

How do you (or your child) feel about:
Your housing?*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
Your ability to support your basic needs of food, housing, etc.?*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
Your safety in your home or where you sleep?*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
Your safety outside your home?*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
Your safety outside your home?*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
How much people in your life support you?*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
Your friendships?*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
Your family situation?*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
Your sense of spirituality, relationship with a higher power, or meaningfulness of life?*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
Your life in general?*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
Have You Received Services From True North Recovery Before?*
- Yes
- No
Please Answer Questions 19 – 21 if you have received services from this agency. Answer each question by choosing the mark that best describes how you feel about each item.

How do you feel about the services you (or your child) received?
I was treated with respect.*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
I was given information about my rights.*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
I was given information about my rights.*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
I helped to choose my treatment goals.*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
I felt comfortable asking questions about my treatment.*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
I was able to get all the services I needed.*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
Because of the services I received:
I am better able to handle daily life.*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
I am getting along better with other people.*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
I am better able to cope when things go wrong.*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
The quality of my life has improved.*
- Terrible
- Unhappy
- Dissatisfied
- Mixed
- Satisfied
- Pleased
- Delighted
20. What did you like about the services you received?*
21. What did you dislike about the services you received?*
22. Did you attend school at any time in the past three months?*
- Yes
- No
If you checked ‘Yes,’ please indicate below the grade/educational level you attended in the past three months.*

Write in Grade Level 1-12 or GED
If you checked ‘No,’ please indicate below the highest grade/educational level you have completed
- Grade Level (Write in Grade Level 1-12 or GED)
- College Undergraduate Freshman (1st year)
- No years of schooling
- College Undergraduate Sophomore (2nd year)
- Nursery School/Pre-School (Including Head Start)
- College Undergraduate Junior (3rd year)
- Kindergarten
- College Undergraduate Senior (4th year)
- Self-Contained Special Education Class (No equivalent grade level)
- Graduate or Professional School (Master’s, Doctoral, Medical, Law)
- Vocational School
24. Which one of the following best describes your employment status during most of the previous week? (please check one)*
- Employed full time working for money (30 or more hours per week); includes Supported Employment and Armed Forces
- Employed part time working for money (less than 30 hours per week); includes Supported Employment and Armed Forces
- Unemployed - actively looking for employment or laid off from job (and awaiting to be recalled) in the past 30 days
- Not in labor/work force (not employed and not actively looking for employment during the past 30 days)
If you checked this box, please check one of the following:
- Homemaker
- Not Yet School Age
- In Residential Care Facility
- Retired
- Student
- In Residential Treatment Facility
- Disabled
- Job training program
- Inpatient of Institutional Care Facility
- Volunteer
- Engaged in subsistence activities
- Inmate of Jail or Correctional Facility
- Sheltered/Non-competitive employment
- Other (please describe)
If "other" please describe
Over the past 7 days, which one of the following best describes the number of hours you engaged in productive activities (e.g., school, employment, volunteering in community service, subsistence activities, etc.)? (Please check one of the boxes below)
- Less than 10 hours
- 10-20 hours
- 21-30 hours
- 31-40 hours
- 41-50 hours
- More than 50 hours

Wasilla

907-313-1333

907-357-8781

591 S. Knik Goose Bay Rd

Wasilla, Alaska 99654

Fairbanks

907-313-1333

4880 Old Airport Way

Fairbanks, Alaska 99709

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