Officer Counselor

Location:

Posted:

May 22, 2022

WRITTEN REPORT

Please fill this out COMPLETELY; do not leave any lines blank. If something does not apply to you, write N/A.

Changes from last month: Address Treatment/Class Provider Employment Vehicle Phone

Today’s Date: Officer:

Name: Other Occupants in Household:

Address: Apt. #: City/State: Zip:

Home Phone: Cell Phone: Other Contact #:

Email:

Employer: Work Days: S M T W Th F Sa

Hours: Salary: $ per Employer know you are on probation? YES NO

If unemployed, means of support and amount: $ per

What jobs have you applied for since your last office visit?

Have you had any call backs or interviews since your last office visit? If so, with which business?

How much do you spend a month on non-essential items? (ex. cable/streaming services, tobacco/alcohol, etc.)

Treatment/Class Provider: Counselor/Instructor:

Treatment/Class Focus: Treatment Provider Phone:

Vehicle (Make/Model/Color): State/Tag #:

Interlock Device Installed? YES NO Interlock Company:

Do you have a valid drivers License? YES NO If yes, State/License #:

If you did NOT drive yourself today, how did you get here?

Any law enforcement contact since your last visit? YES NO

If YES, what was the reason for the contact?

Offender’s Signature Officer’s Signature

*If you are on weekly reporting, credit is only given when Officer’s signature is present*