Monitor Report (Clinical)

Report covers month of:

Name of Participant

Number of informal contacts (telephone, etc.) with the participant during this period?

Number of face-to-face therapy sessions with the participant during this period?

Are there any changes in Axis I through V diagnoses during this period? If yes, please explain in detail below.
YesNoUnknown

Is the participant making progress in terms of behavioral, measurable treatment goals? If not, please explain in detail below.
YesNoUnknown

Has the participant attended his/her scheduled appointments during the month? If not, please explain below.
YesNo

Is the participant demonstrating an attitude of cooperation at this time? If not, please explain below.
YesNo

Has the participant signed the treatment plan demonstrating an understanding of the goals? If not, please explain in detail below.
YesNoN/A

Is the participant capable of practicing law at this time? If not, please explain in detail below.
YesNoUnknown

Monitor Initials:


Please comment on any instances of non-compliance noted on the previous page, on the participant's overall participation in his/her recovery program (therapy, family, professional issues), and provide any recommendations you may have as to how FLA can assist you or the participant in any way. Thank you.

Monitor Name / Signature: