Monthly Report

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Supervising Officer *
Are you currently houseless? *
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Valid License
Employment / Education / Financial
$
Employment Change *
Treatment
I was required to attend: *
Please explain what treatment you are required to attend
Substance Use
In the last 30 days, have you felt a strong urge to drink alcohol or use drugs? *
In the last 30 days, has alcohol/drugs hindered your ability to move forward in life? *
Case Plan
Law Enforcement Contact
Have you had police contact since your last report? *
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Contact Information

Jodi Merritt
Director

Ph.:  (503) 623-5226
Fax: (503) 623-5326
Oregon Relay TTY or Voice: 711

Office Hours
M-F 8:00 A.M. to 5:00 P.M.

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Polk County | 850 Main Street | Dallas, Oregon 97338