This is sample treatment plan and assessment based on a fictional case study.

Client was considered to be in semi-compliance with treatment during this reporting period. Client attended two secheduled groups with two absences. UA were negative for all tested substances. Client reported participating in self-help meeting regularly; verification was provided. Treatment attendance needs to be improved in 30 days.

Met with client for ISP review and to discuss treatment progress. Client appeared to be stable and engaged in the conversation. Client reported that she completed the FAFSA and is planning to go to Everette Community College in the summer. Client reported no use of substances. Client reported coping with temptation by walking away from the situations. Client was reminded that her relapse potential was moderate to high at this time and that she thus would be cautioned to avoid any unintended consequences; with help and support from treatment and her family, client would make his treatment a success. Reviewed ISP in Dim.5 dated 11/29/17, reported completion on approach C, but was unable to identify which peer pressure could be positive (approach

Problem # 5 Illicit opiate use Goal(s): to be free from illicit drugs. Status: Active Objectives/Progress: Pt. has struggled with continued use of illicit drugs (marijuana, opiates and amphetamines) and his last quarter UDS reflect a pattern of heavy substance use. Pt. was encouraged to work with the medical staff to achieve a stable dosing level. Pt. is regularly taking his medication as prescribed by AMS Doctor and he stated his current prescribed methadone 90 mg is working "well". During the last quarter, Pt. made progress on developing a therapeutic relationship with his new AMS counselor for the upcoming quarter. Also, Counselor focused therapy session on establishing rapport and building trust with him. Pt. is currently in the contemplation stage of change because he more open to receiving information about his negative habits and willing to use educational interventions which he agreed with this assessment. Pt. was reinforced for any statement that reflected acceptance of his chemical dependence and acknowledgment of the negative consequences that opiates has had on his life. During the upcoming quarter, Counselor will assist Pt. to discuss and weigh the pros and cons of continuing his addictive

Molly meets the criteria for severe opioid use disorder as evidenced by her recurrent use of opioids, impaired control over substance intake, continued use despite negative consequences, and unsuccessful attempts to cut down or quit. Inpatient detoxification and stabilization is recommended at this time to address Molly's physical dependence on opioids through medically supervised detoxification to manage withdrawal symptoms, stabilize her physiological functioning, and ensure her physical safety during treatment. Molly will benefit from Motivational Interviewing (MI) to increase her intrinsic motivation, enhance her readiness to change, and foster a sense of self-efficacy in her recovery journey. Due to strained relationships with loved ones, family therapy is encouraged to repair

Long term, it is much easier and cheaper to perform preventive health care than to try to manage acute and/ or chronic diseases. All at risk individuals should be given education on the dangers of developing a substance abuse problem, emphasizing that it can happen to anyone- young or old, rich or poor, etc. Health care providers need to address the supposed invincibility commonly associated with those who excessive drink alcohol or use drugs. These individuals are not quite as invincible nor do most have everything as under control as they may think. Although many may know the dangers, it is important to explain that the negative health impacts may not be noticeable right away, but the damage is still being done. Additionally, these at risk patients should work with social workers or case management to set up referrals to substance abuse cessation programs within the

Client comes to treatment because she has been mandated by the court to receive services for her drug and alcohol usage. Client self-reports an extensive history of drug and alcohol usage, as well as, issues with controlling and maintaining her anger. Client is more concerned with her anger issues then her drug and alcohol usage. Client feels that if she can control her anger then she will not have to turn to drugs and alcohol. Client appears to be self-medicating with drugs and alcohol.

The National Center on Addiction and Substance Abuse provides guidelines and recommendations to healthcare providers in terms of how to screen for an addiction. Opioid addiction is screened primarily through patient interviews involving both specific and open ended questions about their lifestyle, mood, and drug use. A psychiatric exam may also be administered to look for psychological factors indicating an addiction such as depression, anxiety, and other psychological symptoms related to addiction and withdrawal. Withdrawal is evaluated by gradually taking a patient off opioids and if symptoms of withdrawal are found the severity of the withdrawal itself is then evaluated.2 If a patient is diagnosed with an addiction to opioids then the transition to tertiary prevention, or treatment will occur. However, treatment will only occur if early detection and screening techniques are utilized fully by healthcare provider otherwise it is likely an overdose will kill the opioid

Plan - The counselor Interventions until next review: Client is to continue current level of treatment to fulfill the court requirement. Counselor will work closely with the probation officer to help the client to complete his treatment successfully. Counselor will continue to motivate and educate to address alcohol use disorder and support remission and long-term

It should be noticed that in the recent few decades, the science developed at an astonishing pace, and the problem of substance abuse cause a huge public concern. Currently, substance abuse has already become a pandemic around the world. It costs individuals substantially, and it of their family as a whole. It is essential for the society to help those people who struggle with drug addiction to get rid of their pain and get back their health and balance life. Therefore, I understand the substance abuse is a tough area, and people who are struggling with addiction really need help. During the course of the interview, I

substance abuse, mental health or co-occurring issues are to link clients to appropriate next step

Contact between an addictions counsellor and a client is usually initiated by the client referring him/her self, an outside agency refers them, family physician or the addictions counsellor initiates contact through outreach or other agencies. Assessment can be seen as the beginning of treatment and it becomes an opportunity to encourage the client to begin to move towards change. The initial assessment involves a mutual investigation and exploration between the client

Addiction treatment is a complex and paradoxical issue. Despite the fact that most of the medical and academic institutions define addiction as a chronic brain disease, it is too often treated on an acute basis. Chronic conditions are defined by the World Health Organization (WHO) as requiring ongoing management over a period of years or decades and cover a wide range of health problems. The goals of chronic care are not to cure, but to enhance functional status, minimize distressing symptoms, prolong life through secondary prevention and enhance quality of life.

The client met with his counselor for his 1x1 session to do follow up in regards to his treatment plan. the client listed the three triggers which are his wife, other female that are involved in using drugs, his mother babying him and disapproving of his life. The client is currently working on money management . the client reported that he is glade that he taking this class because, he never had to handle his own money his wife did it for him. And that he is signing up for SSI he feels this class would be worth it. the client has continue to attend the family groups, and he has completed his first step. The client has also been taking his medication as prescribe. The client at this time seems to be getting past the feeling he has for his wife, and another situation that had happen with another client. He appears to really be trying to learn how not to allow something or someone to cause him to relapse . Counselor will continue meet with the client to address the 6 components of his treatment plan. CADC 1 Yolanda Smith

Assessing those who have an addiction can be cumbersome. Understanding and knowing which assessment tool would be the most useful when it comes to things like type of substance and the type of individual you’re dealing with is important, especially if you want the outcome to be successful. If the assessment tool is too long or difficult to understand the client may become discouraged or agitated, which will lead to refusal to participate. In this paper, tools like the clinical interview, and other assessment instruments that are proven to be useful when assessing those with an addiction will be discussed. It’s not only important to choose the right instrument when assessing those with addiction, but following the proper steps is key when recognizing

When developing a treatment plan for any complex case, it is critical to consider any factors that contribute to the client’s situation. One must generate a plan of action that will support the client appropriately and yet not be overwhelming. It often takes a long time for a client to come to terms that they need help. For many, seeking mental health services can be both a daunting and intimidating laden with feelings of failure and disappointment.