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Evaluations
Midlan Evaluation
Date:
First Name:
Last Name:
Partner if applicable:
Marital Status:
Married
Not Married
Email:
Phone Number:
Write the name of your PO if applicable :
Who was the Provider?:
Chuck
Angela
Julia
Christine b
Daniel Moreno
Angie Ortiz
Michelle Chavez
Susy Burrola
Dr.Barragan
Jesus Campos
Gaby Loya
Maria Gomez
Overall Impression:
Good
Average
Poor
What did you learn from today's topic?:
What would you change about yourself as a result of today’s topic?:
List your families generational substance abuse or domestic violence patterns:
How has the 2ove1, LLC classes/sessions helped you, your family. marriage and/or work?:
Next Session Date and Time:
Evauación en Español
Fecha:
Nombre:
Apellidos:
Nombre de la pareja, si corresponde
Email:
Número de Teléfono:
Nombre del instructor:
Chuck
Angela
Julia
Christine b
Daniel Moreno
Angie Ortiz
Michelle Chavez
Susy Burrola
Dr.Barragan
Jesus Campos
Gaby Loya
Maria Gomez
Impresión General:
Bueno
Promedio
Malo
¿Que aprendiste del tema hoy?:
¿Qué cambiarías de ti mismo como resultado del tema de hoy?:
Liste los patrones generacionales de abuso de sustancias o violencia doméstica de su familia:
¿Qué areas de mejoramiento personal has visto desde tu ultima clase?:
Próxima sesión (fecha y hora)
Phase 1 Evaluation
Date:
First Name:
Last Name:
Email:
Partner Name if applicable:
Marital Status:
Married
Not Married
Phone Number:
Who was the Provider?:
Chuck
Angela
Julia
Christine b
Daniel Moreno
Angie Ortiz
Michelle Chavez
Susy Burrola
Dr.Barragan
Jesus Campos
Gaby Loya
Maria Gomez
Overall Impression:
Good
Average
Poor
Who is willing to participate in your family treatment ?, list their names:
List your biggest struggles right now?:
What expectations and desired outcomes do you have for yourself?:
How can you take what you learned from today’s lesson and apply it to your situation at home or work? :
Next Session Date and Time:
Phase 2 Evaluation
Date:
First Name:
Last Name:
Email:
Partner Name if applicable:
Marital Status:
Married
Not Married
Phone Number:
Who was the Provider?:
Chuck
Angela
Julia
Christine b
Daniel Moreno
Angie Ortiz
Michelle Chavez
Susy Burrola
Dr.Barragan
Jesus Campos
Gaby Loya
Maria Gomez
Overall Impression:
Good
Average
Poor
How can you take what you learned from today’s lesson and apply it to your situation at home or work?
What is your biggest struggle right now?:
Explain the changes you see in yourself:
What goals have you set for yourself and what will help you meet these goals? :
Next Session Date and Time:
Explain if there are changes in your family support? :
Phase 3 Evaluation
Date:
First Name:
Last Name:
Email:
Partner Name if applicable:
Marital Status:
Married
Not Married
Phone Number:
Who was the Provider?:
Chuck
Angela
Julia
Christine b
Daniel Moreno
Angie Ortiz
Michelle Chavez
Susy Burrola
Dr.Barragan
Jesus Campos
Gaby Loya
Maria Gomez
Overall Impression:
Good
Average
Poor
Explain what changes, if any you have made in your marriage, with your family or with your children:
Explain what behaviors do you need to change if any to help you and why:
What things are you implementing or doing to have a stable, habitable, drug & alcohol free residence?:
List the family obstacles or generational patterns you have identified :
Explain what you have learned in treatment/2love1:
Next Session Date and Time:
Phase 4 Evaluation
Date:
First Name:
Last Name:
Email:
Partner Name if applicable:
Marital Status:
Married
Not Married
Phone Number:
Who was the Provider?:
Chuck
Angela
Julia
Christine b
Daniel Moreno
Angie Ortiz
Michelle Chavez
Susy Burrola
Dr.Barragan
Jesus Campos
Gaby Loya
Maria Gomez
Overall Impression:
Good
Average
Poor
List your biggest accomplishments or what are you most proud of? :
Explain what goals you have set for you and your family:
How do your values differ from your friends and family?:
What life experiences led you to your current values & beliefs? :
How can you take what you learned from today’s lesson and apply it to your situation at home or work?:
Next Session Date and Time:
Phase 5 Evaluation
Date:
First Name:
Last Name:
Email:
Partner Name if applicable:
Marital Status:
Married
Not Married
Phone Number:
Who was the Provider?:
Chuck
Angela
Julia
Christine b
Daniel Moreno
Angie Ortiz
Michelle Chavez
Susy Burrola
Dr.Barragan
Jesus Campos
Gaby Loya
Maria Gomez
Overall Impression:
Good
Average
Poor
What have you learned in treatment to help with situations that will impair your recovery? :
How are you keeping your home stable, habitable and drug and alcohol free?:
What character flaws have you changed as a result of what you have learned at 2love1?:
What goals are you currently working on to maintain lifelong sobriety and avoid criminal activity? :
Explain what you learned in your session today in your own words:
Next Session Date and Time: