General Information:
1. In relation to your general mental health, summarize your progression/regression over the past thirty days:
2. Document your experiences with the following:
Behavior
3. Using the scale below, rate the positive impact that your recovery efforts over the past thirty days have had on your: (1-No effect 2-Slight 3-Moderate 4-Considerable 5-Extreme)
4. Using the scale below, rate the negative impact that your sexual and/or romantic behaviors over the past thirty days have had on your: (1-No effect 2-Slight 3-Moderate 4-Considerable 5-Extreme)
5) Summarize the progress made towards your existing recovery and life goals over the past thirty days:
6) Describe the closest you came to a slip/relapse over the past month:
7) List the most likely relapse triggers you will face in the coming month:
8) Approximate (in percentages) the amount of time over the past month that you have spent:
* Cooking, cleaning, laundry, mowing the lawn, etc
9) Overall, how would you rate your emotional state over the past thirty days:
a) At it's healthiest: Extremely Healthy Very Healthy Healthy Close to Healthy Fairly Unhealthy Very Unhealthy Extremely Unhealthy b) At it's unhealthiest: Extremely Healthy Very Healthy Healthy Close to Healthy Fairly Unhealthy Very Unhealthy Extremely Unhealthy c) Overall: Extremely Healthy Very Healthy Healthy Close to Healthy Fairly Unhealthy Very Unhealthy Extremely Unhealthy
