Refuge House Forms Library

Youth Information

Name *

Case Number *

Date of Birth

SU Package Placement Date

Current Foster Home

Sobriety Progress

days of sobriety

Sobriety Start Date

Current Recovery Status

Recovery Milestones

Progress Summary

Recovery Indicators0/6

Milestones0/5

Treatment Information

Primary Substance of Concern

Secondary Substances (if any)

Treatment Start Date

Treatment Provider

Therapist Name

Therapy Frequency

Youth is on Medication-Assisted Treatment (MAT)

Treatment Engagement

Individual Therapy Attendance

Group Participation

Recovery Meetings (AA/NA)

Has sponsor/recovery mentor

Recovery Indicators

Track positive progress in recovery journey

Developing healthy coping skills

Identifying and managing triggers

Building healthy relationships

School/work engagement improving

Family relationships improving

Positive community involvement

Setbacks & Relapses

Document in recovery-focused, non-punitive manner per FC-SU-01

Remember: Relapse is often part of the recovery journey. Focus on learning, growth, and re-engagement rather than punishment.

Number of Relapses During Treatment

Most Recent Relapse Date (if any)

Goals & Progress Notes

Short-Term Recovery Goals (next 30-90 days)

Long-Term Recovery Goals

Current Barriers to Progress

Progress Notes

Concerns or Flags

Review Information

Review Date

Reviewed By

Next Review Date

Recovery Progress Tracker

Recovery-Focused Approach