"Map Aftercare Report" - Mississippi

Map Aftercare Report is a legal document that was released by the Mississippi Board Of Nursing - a government authority operating within Mississippi.

Form Details:

  • Released on January 1, 2001;
  • The latest edition currently provided by the Mississippi Board Of Nursing;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Board of Nursing.

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COMPLIANCE DIVISION
MAP AFTERCARE REPORT
The following is an example of information that is to be included in the Aftercare Report.
Name of Agency:
__________________________________________________________
Name of Participant:
__________________________________________________________
For the Month Of:
__________________________________________________________
Date Entered Program
___________________
Time in Program: ______________________
ATTENDANCE:
Client has attended ______ of ______ scheduled sessions.
Number of absences ______
Client had prior approval for absence: ______ Yes
______ No.
Sessions made up: ___________________.
Reason for non-attendance: ______________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Client has been on time for sessions: ______ Yes
______ No.
Number of times tardy: ______.
Reason for tardiness: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PROGRESS:
Poor
Fair
Good
Excellent
Participation in groups
_____
_____
_____
_____
Recognition of disease in self
_____
_____
_____
_____
Accepting responsibility for self
_____
_____
_____
_____
Operating on a feeling level
_____
_____
_____
_____
Able to give feedback to others
_____
_____
_____
_____
th
th
Completion of 4
and 5
steps
_____
_____
_____
_____
Participation in informational lectures
_____
_____
_____
_____
Overall demonstrated level of motivation
_____
_____
_____
_____
Attitude toward AA/NA/CA
_____
_____
_____
_____
General Statement About Client:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
SIGNATURE/TITLE
OF
PREPARER:
__________________________________________________________
DATE: ______________________________
January 2001
vg
COMPLIANCE DIVISION
MAP AFTERCARE REPORT
The following is an example of information that is to be included in the Aftercare Report.
Name of Agency:
__________________________________________________________
Name of Participant:
__________________________________________________________
For the Month Of:
__________________________________________________________
Date Entered Program
___________________
Time in Program: ______________________
ATTENDANCE:
Client has attended ______ of ______ scheduled sessions.
Number of absences ______
Client had prior approval for absence: ______ Yes
______ No.
Sessions made up: ___________________.
Reason for non-attendance: ______________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Client has been on time for sessions: ______ Yes
______ No.
Number of times tardy: ______.
Reason for tardiness: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PROGRESS:
Poor
Fair
Good
Excellent
Participation in groups
_____
_____
_____
_____
Recognition of disease in self
_____
_____
_____
_____
Accepting responsibility for self
_____
_____
_____
_____
Operating on a feeling level
_____
_____
_____
_____
Able to give feedback to others
_____
_____
_____
_____
th
th
Completion of 4
and 5
steps
_____
_____
_____
_____
Participation in informational lectures
_____
_____
_____
_____
Overall demonstrated level of motivation
_____
_____
_____
_____
Attitude toward AA/NA/CA
_____
_____
_____
_____
General Statement About Client:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
SIGNATURE/TITLE
OF
PREPARER:
__________________________________________________________
DATE: ______________________________
January 2001
vg