Personal Decision Making Monthly Report Form

Date:
Meeting Place:	Prison Rehab
Day/Time:
Client:
Tutor:

Over the last 4 sessions:

Client Progress:

Comments:

Match Termination Information

Match Termination Reason:

Date Certificate Given:

Match Evaluation Comments:

Please call Donna if you are thinking about continuing to meet after your client receives a certificate.

I am ready for another client I will be ready for another client

Date I will be ready for client:

Client Name:

Tutor Name:

For each session, please read each statement and choose the number that best describes each category.

Date:

Hours Tutored: Hours Prep: Lesson #: Step:

	Poor to Great	Comments
Session Evaluation:	1 2 3 4 5
Client - participation:	1 2 3 4 5
Client - on time:	1 2 3 4 5

Date:

Hours Tutored: Hours Prep: Lesson #: Step:

	Poor to Great	Comments
Session Evaluation:	1 2 3 4 5
Client - participation:	1 2 3 4 5
Client - on time:	1 2 3 4 5

Date:

Hours Tutored: Hours Prep: Lesson #: Step:

	Poor to Great	Comments
Session Evaluation:	1 2 3 4 5
Client - participation:	1 2 3 4 5
Client - on time:	1 2 3 4 5

Date:

Hours Tutored: Hours Prep: Lesson #: Step:

	Poor to Great	Comments
Session Evaluation:	1 2 3 4 5
Client - participation:	1 2 3 4 5
Client - on time:	1 2 3 4 5

If Your client did not attend the session, please note in the additional comments section. Thank You