ASAM Criteria® Treatment Planning Template Instructions
This form contains 259 fields organized into 68 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Accommodations | ||
| Drug testing/Breathalyzer | Checkbox |
Check this box if drug testing or breathalyzer services are provided as an accommodation.
|
| Harm reduction services | Checkbox |
Check this box if harm reduction services are provided as an accommodation.
|
| Overdose reversal training | Checkbox |
Check this box if overdose reversal training is provided as part of harm reduction services.
|
| Accommodations Provided | Text |
Provide a detailed description of the accommodations that will be provided to enable the patient to participate in treatment.
|
| Anticipated medical support needs | ||
| Anticipated Medical Support Needs | Text |
Provide details on the anticipated medical support needs, such as mobility assistance, dialysis, or wound care.
|
| Anticipated medication-related needs | ||
| Anticipated Medication-Related Needs | Text |
Provide details regarding the anticipated medication-related needs.
|
| Anticipated need for mental health services | ||
| Anticipated Mental Health Services | Text |
Enter the anticipated mental health services required.
|
| Anticipated next level of care | ||
| Anticipated Next Level of Care | Combobox |
Please provide the anticipated next level of care for the individual.
3.7 BIO: Medically Managed Biomedically Enhanced Residential Treatment
2.1 Intensive Outpatient Treatment
2.5 COE - Co-Occurring Enhanced High-Intensity Outpatient Treatment
2.5 High-Intensity Outpatient Treatment
3.1 Clinically Managed Low-Intensity Residential Treatment
Choose Item
3.7 Medically Managed Residential Treatment
3.7 COE - Co-Occurring Enhanced Medically Managed Residential Treatment
4 Psychiatric
4 Medically Managed Inpatient Treatment
1.5 Outpatient Therapy
2.7 Medically Managed Intensive Outpatient Treatment
1.7 COE - Co-Occurring Enhanced Medically Managed Outpatient Treatment
1.5 COE - Co-Occurring Enhanced Outpatient Therapy
3.5 COE - Co-Occurring Enhanced Clinically Managed High-Intensity Residential Treatment
1.7 Medically Managed Outpatient Treatment
3.5 Clinically Managed High-Intensity Residential Treatment
1.0 Long-Term Remission Monitoring
|
| Care Coordination Needs | ||
| Care Coordination Needs | Text |
Identify the responsible staff member, the external provider they will coordinate with, and the services provided (eg, psychiatric services, HIV care).
|
| Counseling and Case Management | ||
| Individual Counseling Sessions | Text |
Enter the number of individual counseling sessions per week.
|
| Group Counseling Sessions | Text |
Enter the number of group counseling sessions per week.
|
| Case Management Sessions | Text |
Enter the number of case management sessions per week.
|
| Counseling and Case Management Frequency | ||
| Does this client require naloxone? Select this box if the answer is yes | CheckBox | |
| Does this client require safer use education? Select this box if the answer is yes | CheckBox | |
| Does this client require safer sex education? Select this box if the answer is yes | CheckBox | |
| Does this client require referral to harm reduction organization | CheckBox | |
| Mutual support group | Checkbox |
Check this box if the patient will participate in a mutual support group, and then indicate the frequency of participation per week.
|
| Patient navigation | Checkbox |
Check this box if the patient receives or will receive patient navigation services.
|
| Crisis Intervention | ||
| Individual counseling | Checkbox |
Check this box if the patient will receive individual counseling as part of their service plan.
|
| Group counseling | Checkbox |
Check this box if the patient will receive group counseling as part of their service plan.
|
| Date of Last Crisis Intervention | Date |
Provide the date of the patient's last crisis intervention.
|
| Diagnoses | ||
| Diagnosis 1 | Text |
Enter the patient's first diagnosis as a descriptive name or clinical code (for example, ICD-10).
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| Diagnosis 2 | Text |
Enter the patient's second diagnosis as a descriptive name or clinical code (for example, ICD-10).
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| Diagnosis 3 | Text |
Enter the patient's third diagnosis as a descriptive name or clinical code (for example, ICD-10).
|
| Diagnosis 4 | Text |
Enter the patient's fourth diagnosis as a descriptive name or clinical code (for example, ICD-10).
|
| Diagnosis 5 | Text |
Enter the patient's fifth diagnosis as a descriptive name or clinical code (for example, ICD-10).
|
| Diagnosis 6 | Text |
Enter the patient's sixth diagnosis as a descriptive name or clinical code (for example, ICD-10).
|
| Diagnosis 7 | Text |
Enter the patient's seventh diagnosis as a descriptive name or clinical code (for example, ICD-10).
|
| Diagnosis 8 | Text |
Enter the patient's eighth diagnosis as a descriptive name or clinical code (for example, ICD-10).
|
| Drug Testing Details | ||
| Medication management | Checkbox |
Check this box if medication management services are to be provided.
|
| Case management | Checkbox |
Check this box if case management services are to be provided.
|
| Is this client requiring medical services? Select this box if the anser is yes | CheckBox | |
| Is this client requiring mental health services? Select this box if the answer is yes | CheckBox | |
| Drug Testing/Breathalyzer | ||
| Date of Last Test | Date |
Enter the date the last drug test or breathalyzer was administered.
|
| Anticipated Testing Frequency | Text |
Specify the anticipated frequency of drug testing or breathalyzer.
|
| Clinical Purpose of Drug Testing | Text |
Describe the clinical purpose for drug testing or breathalyzer.
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| Educational Services | ||
| Educational Services Other (specify) | Text |
Enter any other educational services not listed.
|
| First Dimension and Risk Rating | ||
| First Risk Rating | Text |
Enter the current risk rating for the first dimension or subdimension.
|
| First Dimension/Subdimension | Text |
Provide the first dimension or subdimension related to the problem.
|
| First Risk Rating | Text |
Enter the current risk rating for the first dimension/subdimension.
|
| First Dimension/Subdimension | Text |
Enter the first dimension or subdimension related to the problem.
|
| First Dimension Row (Dimension/Subdimension & Current Risk Rating) | ||
| 1. Current Risk Rating | Text |
Enter the current risk rating for the first dimension/subdimension (e.g., a word like Low, Medium, High or a short numeric score) that describes its assessed risk level.
|
| 1. Dimension/Subdimension | Text |
Enter the name or short label of the first dimension or subdimension being assessed. Fill only if 'Dimensional Driver (line 1) - Yes' is 'Yes'.
|
| First Dimension Row - Dimensional Driver: Yes | Checkbox |
Check this box if the dimensional driver applies (Yes) to the first listed dimension/subdimension.
|
| First Dimension Row - Dimensional Driver: No | Checkbox |
Check this box if the dimensional driver does NOT apply (No) to the first listed dimension/subdimension.
|
| First Dimension/Subdimension and Risk Rating | ||
| First Dimension/Subdimension | Text |
Enter the first dimension or subdimension related to the problem.
|
| First Current Risk Rating | Text |
Enter the current risk rating for the first dimension or subdimension.
|
| First Objective and Action Steps | ||
| Middle Name 81 | Text | |
| NameAndAddress 6 | Text | |
| First Objective | Text |
Enter the first objective to be achieved.
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| First Objective Action Step A | Text |
Enter the first action step (a) to achieve the first objective.
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| Middle Name 83 | Text | |
| First Objective Action Step B | Text |
Enter the second action step (b) to achieve the first objective.
|
| Middle Name 84 | Text | |
| First Objective Action Step C | Text |
Enter the third action step (c) to achieve the first objective.
|
| NameAndAddress 8 | Text | |
| Middle Name 143 | Text | |
| First Objective | Text |
Enter the first objective.
|
| First Action Step (a) | Text |
Enter the first action step (a) for the first objective.
|
| Middle Name 148 | Text | |
| First Action Step (b) | Text |
Enter the second action step (b) for the first objective.
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| Middle Name 149 | Text | |
| First Action Step (c) | Text |
Enter the third action step (c) for the first objective.
|
| Middle Name 163 | Text | |
| NameAndAddress 10 | Text | |
| First Objective Action Step A | Text |
Provide the first action step (a) for the first objective.
|
| First Objective | Text |
Provide the first objective.
|
| Middle Name 171 | Text | |
| First Objective Action Step B | Text |
Provide the second action step (b) for the first objective.
|
| Middle Name 172 | Text | |
| First Objective Action Step C | Text |
Provide the third action step (c) for the first objective.
|
| First Subdimension Row | ||
| First Subdimension - Subdimension Name | Text |
Enter the name or label of the first subdimension being assessed (a short descriptive title).
|
| First Subdimension - Risk Description | Text |
Provide a clear description of the patient’s risks, concerns, or specific issues related to the first subdimension. Fill only if 'First Subdimension - Subdimension Name' is 'Yes'.
|
| Fourth Objective and Action Steps | ||
| Fourth Objective Action Step A | Text |
Provide the first action step for the fourth objective.
|
| Fourth Objective | Text |
Provide the fourth objective.
|
| Fourth Objective Action Step B | Text |
Provide the second action step for the fourth objective.
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| Fourth Objective Action Step C | Text |
Provide the third action step for the fourth objective.
|
| Fourth Action Step A | Text |
Please describe the first action step for the fourth objective.
|
| Fourth Objective | Text |
Please provide the fourth objective for this problem.
|
| Fourth Action Step B | Text |
Please describe the second action step for the fourth objective.
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| Fourth Action Step C | Text |
Please describe the third action step for the fourth objective.
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| Fourth Action Step A | Text |
Please enter the first action step for the fourth objective.
|
| Fourth Objective | Text |
Please enter the fourth objective.
|
| Fourth Action Step B | Text |
Please enter the second action step for the fourth objective.
|
| Fourth Action Step C | Text |
Please enter the third action step for the fourth objective.
|
| Fourth Subdimension Row | ||
| Fourth Subdimension - Name | Text |
Enter the name or short label of the fourth subdimension (the specific sub-area or domain being assessed).
|
| Fourth Subdimension - Risk Description | Text |
Describe the patient’s risks, concerns, or issues related to the fourth subdimension in a few clear sentences. Fill only if 'Fourth Subdimension - Name' is 'Yes'.
|
| General | ||
| clearly state the third action step for the first objective of problem one | Text | |
| clearly state the first action step for the second objective of problem one | Text | |
| Dimension 1 Dimensional Driver Yes | Checkbox |
Check this box if the first dimension's dimensional driver is 'Yes'.
|
| Dimension 1 Dimensional Driver No | Checkbox |
Check this box if the first dimension's dimensional driver is 'No'.
|
| Dimension 2 Dimensional Driver Yes | Checkbox |
Check this box if the second dimension's dimensional driver is 'Yes'.
|
| Dimension 2 Dimensional Driver No | Checkbox |
Check this box if the second dimension's dimensional driver is 'No'.
|
| Dimension 3 Dimensional Driver Yes | Checkbox |
Check this box if the third dimension's dimensional driver is 'Yes'.
|
| Dimension 3 Dimensional Driver No | Checkbox |
Check this box if the third dimension's dimensional driver is 'No'.
|
| Dimensional Driver 1 Yes | Checkbox |
Check this box if the first dimensional driver is present or applicable.
|
| Dimensional Driver 1 No | Checkbox |
Check this box if the first dimensional driver is 'No'.
|
| Dimensional Driver 2 Yes | Checkbox |
Check this box if the second dimensional driver is 'Yes'.
|
| Dimensional Driver 2 No | Checkbox |
Check this box if the second dimensional driver is 'No'.
|
| Dimensional Driver 3 Yes | Checkbox |
Check this box if the third dimensional driver is 'Yes'.
|
| Dimensional Driver 3 No | Checkbox |
Check this box if the third dimensional driver is 'No'.
|
| Dimensional Driver 1 Yes | Checkbox |
Check this box if the first item is identified as a dimensional driver.
|
| Dimensional Driver 1 No | Checkbox |
Check this box if the first item is not identified as a dimensional driver.
|
| Dimensional Driver 2 Yes | Checkbox |
Check this box if the second item is identified as a dimensional driver.
|
| Dimensional Driver 2 No | Checkbox |
Check this box if the second item is not identified as a dimensional driver.
|
| Dimensional Driver 3 Yes | Checkbox |
Check this box if the third item is identified as a dimensional driver.
|
| Dimensional Driver 3 No | Checkbox |
Check this box if the third item is not identified as a dimensional driver.
|
| patient signature in this space | Signature | |
| parent or guardian signature in this space | Signature | |
| clinician signature and credentials in this space | Signature | |
| clinical supervisor signature in this space if applicable | Signature | |
| Goal | ||
| Goal | Text |
Provide a clear statement of the goal for this problem.
|
| Goal | Text |
Enter the specific goal or objective for the problem.
|
| Goal | Text |
Provide a concise statement outlining the objective or desired outcome for this problem.
|
| Goal Dates | ||
| Target date | Date |
Enter the target date for the goal.
|
| Completion date | Date |
Enter the completion date for the goal.
|
| Target Date | Date |
Enter the target date for the goal.
|
| Completion Date | Date |
Enter the completion date for the goal.
|
| Harm reduction service needs | ||
| Harm Reduction Service Needs | Text |
Enter the harm reduction service needs.
|
| Harm Reduction Services | ||
| Harm Reduction Services Other | Text |
Please provide details for any other harm reduction services not explicitly listed.
|
| Medical Services | ||
| Medical Services Physical Exam Date | Date |
Enter the date of the physical exam.
|
| Medical Services Primary Care Appointment Date | Date |
Enter the date of the primary care appointment.
|
| Medical Services Specialist Appointment | Text |
Enter details about the specialist appointment, including its type and date.
|
| Medical Services Prenatal Postnatal Appointment Date | Date |
Enter the date of the prenatal or postnatal appointment.
|
| Medical Services Dental Appointment Date | Date |
Enter the date of the dental appointment.
|
| Medical Services Other Details | Text |
Enter details about any other medical services and their appointment dates.
|
| Medical Services Appointment Dates | ||
| Social service navigation | Checkbox |
Check this box if the patient requires assistance with navigating social services.
|
| Housing services | Checkbox |
Check this box if the patient needs assistance obtaining housing services.
|
| Transportation support | Checkbox |
Check this box if the patient requires support with transportation.
|
| Supplemental nutrition benefits | Checkbox |
Check this box if the patient needs access to supplemental nutrition benefits.
|
| Health insurance | Checkbox |
Check this box if the patient requires assistance with health insurance.
|
| Intimate partner violence services | Checkbox |
Check this box if the patient needs support related to intimate partner violence services.
|
| Legal services | Checkbox |
Check this box if the patient requires legal assistance.
|
| Medication Management | ||
| Medication Management Last Appointment | Date |
Enter the date of the patient's last medication management appointment.
|
| Medication Management Next Appointment | Date |
Enter the date of the patient's next medication management appointment.
|
| Medication Management Appointments | ||
| Does this client require other harm reduction services? Select this box if the answer is yes | CheckBox | |
| Is this client requiring recovery support services? Select this box if the answer is yes | CheckBox | |
| Is this client requiring peer support services? Select this box if the answer is yes | CheckBox | |
| Mental Health Services | ||
| Child Protective Services | Checkbox |
Check this box if the patient is receiving child protective services.
|
| Educational Services | Checkbox |
Check this box if the patient is receiving educational services.
|
| Parenting | Checkbox |
Check this box if the patient is receiving parenting services.
|
| Financial Management | Checkbox |
Check this box if the patient is receiving financial management services.
|
| Self-Care | Checkbox |
Check this box if the patient is receiving self-care services.
|
| Other (Specify) | Checkbox |
Check this box if the patient is receiving other unlisted services and provide specific details.
|
| Mental Health Group Counseling Frequency | Text |
Enter the number of times per week the patient receives mental health group counseling.
|
| Mental Health Individual Counseling Frequency | Text |
Enter the number of times per week the patient receives mental health individual counseling.
|
| Psychiatric Assessment Date | Date |
Enter the date of the psychiatric assessment.
|
| Cognitive Assessment Date | Date |
Enter the date of the cognitive assessment.
|
| Other Mental Health Service | Text |
Enter any other mental health service provided not explicitly listed.
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| Objective 1 and Action Steps | ||
| Objective 1 - Objective | Text |
Enter the full statement of Objective 1 that describes the goal to be achieved for this project or process.
|
| Objective 1 - Action Step a | Text |
Enter the first action step (a) that will be taken to accomplish Objective 1, including a short description of the activity. Fill only if 'Objective 1 - Objective' is filled.
|
| Objective 1 - Action Step b | Text |
Enter the second action step (b) that will be taken to accomplish Objective 1, including a short description of the activity. Fill only if 'Objective 1 - Objective' is filled.
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| Objective 2 and Action Steps | ||
| Objective 2 — Action Step a | Text |
Enter the first action step (a) for Objective 2 as a short, actionable task describing what will be done to progress toward the objective. Fill only if 'Objective 2 — Statement' is filled.
|
| Objective 2 — Statement | Text |
Enter the full written statement of Objective 2: a concise, specific goal describing the desired outcome to be achieved.
|
| Objective 2 — Action Step b | Text |
Enter the second action step (b) for Objective 2 as a brief, specific task that explains the next activity to be completed. Fill only if 'Objective 2 — Statement' is filled.
|
| Objective 2 — Action Step c | Text |
Enter the third action step (c) for Objective 2 as a concise description of the activity or task to be carried out. Fill only if 'Objective 2 — Statement' is filled.
|
| Objective 3 and Action Steps | ||
| Objective 3 – Description | Text |
Enter the full text of the third objective: a concise, specific statement of what this objective intends to achieve.
|
| Objective 3 – Action Step a | Text |
Enter the first action step (a) for achieving Objective 3, describing the task to be done and who is responsible. Fill only if 'Objective 3 – Description' is filled.
|
| Objective 3 – Action Step b | Text |
Enter the second action step (b) for achieving Objective 3, describing the task to be done and who is responsible. Fill only if 'Objective 3 – Description' is filled.
|
| Objective 3 – Action Step c | Text |
Enter the third action step (c) for achieving Objective 3, describing the task to be done and who is responsible. Fill only if 'Objective 3 – Description' is filled.
|
| Objective 4 and Action Steps | ||
| Objective 4 — Objective | Text |
Enter the full text of Objective 4: a concise, patient-centered statement of the goal to be achieved.
|
| Objective 4 — Action Step a | Text |
Enter the first action step (a) to achieve Objective 4, describing the specific task or intervention and who is responsible. Fill only if 'Objective 4 — Objective' is filled.
|
| Objective 4 — Action Step b | Text |
Enter the second action step (b) to achieve Objective 4, describing the specific task or intervention and who is responsible. Fill only if 'Objective 4 — Objective' is filled.
|
| Objective 4 — Action Step c | Text |
Enter the third action step (c) to achieve Objective 4, describing the specific task or intervention and who is responsible. Fill only if 'Objective 4 — Objective' is filled.
|
| Page 9 | ||
| Patient Signature Date | Date |
Enter the date the patient signed the document.
|
| Explanation for Unable to Sign | Text |
Provide an explanation if the patient is unable to sign the treatment plan.
|
| Patient Identification (name, counselor, level of care) | ||
| Patient's name | Text |
Enter the patient’s full name (first and last) as it appears in their medical record.
|
| Primary counselor's name | Text |
Enter the full name of the patient’s primary counselor responsible for this treatment plan.
|
| Recent physical exam: Yes | Checkbox |
Check this box if the patient has had a recent physical exam.
|
| Recent physical exam: No | Checkbox |
Check this box if the patient has not had a recent physical exam.
|
| Level of care | Combobox |
Enter the assigned level of care for the patient (e.g., ASAM level designation or other specified level).
3.7 BIO: Medically Managed Biomedically Enhanced Residential Treatment
2.1 Intensive Outpatient Treatment
2.5 COE - Co-Occurring Enhanced High-Intensity Outpatient Treatment
2.5 High-Intensity Outpatient Treatment
3.1 Clinically Managed Low-Intensity Residential Treatment
Choose Item
3.7 Medically Managed Residential Treatment
3.7 COE - Co-Occurring Enhanced Medically Managed Residential Treatment
4 Psychiatric
4 Medically Managed Inpatient Treatment
1.5 Outpatient Therapy
2.7 Medically Managed Intensive Outpatient Treatment
1.7 COE - Co-Occurring Enhanced Medically Managed Outpatient Treatment
1.5 COE - Co-Occurring Enhanced Outpatient Therapy
3.5 COE - Co-Occurring Enhanced Clinically Managed High-Intensity Residential Treatment
1.7 Medically Managed Outpatient Treatment
3.5 Clinically Managed High-Intensity Residential Treatment
1.0 Long-Term Remission Monitoring
|
| Patient Priorities | ||
| Priority 1 | Text |
Enter the patient's top priority or goal in one short sentence or phrase describing what matters most to them right now.
|
| Priority 2 | Text |
Enter the patient's second most important priority or goal as a concise sentence or phrase describing their next most important concern.
|
| Priority 3 | Text |
Enter the patient's third priority or goal as a brief sentence or phrase describing another important concern or objective.
|
| Patient strengths and abilities | ||
| Patient strengths and abilities to support this goal | Text |
Enter the patient’s strengths, skills, supports, and resources (personal, social, and community recovery capital) that will help achieve this specific goal.
|
| Physical Exam Date | ||
| Physical Exam Date | Date |
Enter the date the patient’s physical exam was performed or the date it is scheduled. Fill only if 'Recent physical exam: Yes' is 'Yes'.
|
| Prevention Strategies | ||
| Prevention Strategies | Text |
Provide the strategies you will use to prevent risks to your safety and/or recovery.
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| Problem Statement | ||
| Problem 2 Statement | Text |
Provide a concise statement describing Problem 2.
|
| Problem 3 Statement | Text |
Enter the detailed statement for Problem 3.
|
| Problem 4 Statement | Text |
Enter the problem statement for Problem 4.
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| Problem Statement and Goal | ||
| Problem Statement | Text |
Enter a concise description of the problem to be addressed, stating the issue, context, and why it is important.
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| Goal | Text |
Enter the specific objective or desired outcome that will resolve or mitigate the problem, stated clearly and measurably if possible.
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| Dimensional Driver (line 1) - Yes | Checkbox |
Check this box when the first listed dimension/subdimension is a dimensional driver (i.e., it does drive the problem) to indicate 'Yes'.
|
| Dimensional Driver (line 1) - No | Checkbox |
Check this box when the first listed dimension/subdimension is not a dimensional driver to indicate 'No'.
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| Progress towards goal and objectives | ||
| Progress toward goal and objectives (narrative) | Text |
Enter a concise narrative describing the patient’s progress toward the stated goal and objectives, including measurable changes, barriers encountered, supports used, and any next steps or recommended adjustments.
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| Progress Towards Goal and Objectives | Text |
Provide a detailed description of the progress made towards the stated goal and objectives.
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| Progress towards goal and objectives | Text |
Provide details regarding the progress made towards the stated goal and objectives.
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| Progress Towards Goal and Objectives | ||
| Progress Towards Goal and Objectives | Text |
Provide a detailed description of the progress made towards the established goal and objectives.
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| Reasons to Call 911 | ||
| Reason to Call 911 | Text |
State the specific reason(s) for which you would call 911.
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| Reasons to Call 988 | ||
| Reasons to Call 988 | Text |
Specify the reasons or situations that would prompt calling 988.
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| Recovery support service needs | ||
| Recovery Support Service Needs | Text |
Enter the recovery support service needs.
|
| Recovery Support Services | ||
| Is this client requiring crisis intervention? Select this box if the answer is yes | CheckBox | |
| Peer Support Services Frequency | Number |
Enter the number of times peer support services are provided per week.
|
| Mutual Support Group Frequency | Number |
Enter the number of times mutual support group services are provided per week.
|
| Patient Navigation Details | Text |
Provide specific details regarding patient navigation services.
|
| are accommodations needed to enable the patient to participate?_yes | CheckBox | |
| No | Checkbox |
Check this box if no accommodations are needed to enable the patient to participate in treatment.
|
| Referral needs | ||
| Referral Needs | Text |
Provide a detailed explanation of any referral needs.
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| Risk Factors | ||
| Specific Risk Factors | Text |
Provide details on what you are at risk for, such as return to use, risky behavior, or self-harm.
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| Second Dimension and Risk Rating | ||
| Second Risk Rating | Text |
Enter the current risk rating for the second dimension.
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| Second Dimension | Text |
Enter the name of the second dimension or subdimension.
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| Second Current Risk Rating | Text |
Enter the current risk rating for the second item.
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| Second Dimension/Subdimension | Text |
Provide the name of the second dimension or subdimension relevant to the problem.
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| Second Dimension Row (Dimension/Subdimension & Current Risk Rating) | ||
| Second Current Risk Rating | Text |
Enter the current risk rating for the second dimension/subdimension shown on this row (provide the rating value or short rating label).
|
| Second Dimension/Subdimension | Text |
Enter the name or short code of the second dimension or subdimension relevant to this problem row (e.g., a descriptive label or category). Fill only if 'First Dimension Row - Dimensional Driver: Yes' is 'Yes'.
|
| Second Dimension - Dimensional Driver: No | Checkbox |
Check this box when, for the second listed dimension/subdimension in this row, the answer to 'Dimensional Driver' is No.
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| Second Dimension/Subdimension and Risk Rating | ||
| Second Dimension/Subdimension | Text |
Provide the name or description of the second dimension or subdimension.
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| Second Current Risk Rating | Text |
Enter the current risk rating for the second dimension or subdimension.
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| Second Objective and Action Steps | ||
| Second Objective | Text |
Please enter the text for the second objective.
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| Second Objective Action Step A | Text |
Please enter the text for the first action step of the second objective.
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| Second Objective Action Step B | Text |
Please enter the text for the second action step of the second objective.
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| Second Objective Action Step C | Text |
Please enter the text for the third action step of the second objective.
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| Second Objective | Text |
Please provide the second objective.
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| Second Objective Action Step A | Text |
Please describe the first action step for the second objective.
|
| Second Objective Action Step B | Text |
Please describe the second action step for the second objective.
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| Second Objective Action Step C | Text |
Please describe the third action step for the second objective.
|
| Second Objective | Text |
Please provide the second objective.
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| Second Objective Action Step A | Text |
Please provide the first action step for the second objective.
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| Second Objective Action Step B | Text |
Please provide the second action step for the second objective.
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| Second Objective Action Step C | Text |
Please provide the third action step for the second objective.
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| Second Subdimension Row | ||
| Second Subdimension | Text |
Enter the name or brief label of the second subdimension being assessed in this row.
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| Second Subdimension - Risk Description | Text |
Describe the patient's risks, concerns, or relevant clinical information for the second subdimension in a few clear sentences. Fill only if 'Second Subdimension' is 'Yes'.
|
| Services needed to prepare for transition | ||
| Services Needed to Prepare for Transition | Text |
Provide a description of the services needed to prepare for transition, including examples like housing or transportation.
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| Stage of Change | ||
| Stage of Change | Text |
Enter the stage of change for this problem.
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| Stage of change for this problem | ||
| Stage of change for this problem | Text |
Enter the patient's current stage of change for this specific problem (for example: Precontemplation, Contemplation, Preparation, Action, Maintenance, or the corresponding stage number).
|
| Stage of Change for Problem | Text |
Enter the stage of change for this problem.
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| Stage of Change for this Problem | Text |
Enter the stage of change for this problem.
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| Target and Completion Dates | ||
| Target date | Date |
Enter the planned target date by which the goal or objective is intended to be achieved.
|
| Completion date | Date |
Enter the actual completion date when the goal or objective was finished or reached.
|
| Target Date | Date |
Enter the target date for the goal.
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| Completion Date | Date |
Enter the completion date for the goal.
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| Third Dimension and Risk Rating | ||
| Third Current Risk Rating | Number |
Provide the current risk rating for the third dimension.
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| Third Dimension/Subdimension | Text |
Provide the third dimension or subdimension.
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| Third Risk Rating | Text |
Please provide the current risk rating for the third dimension.
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| Third Dimension/Subdimension | Text |
Please provide the third dimension or subdimension.
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| Third Dimension Row (Dimension/Subdimension & Current Risk Rating) | ||
| Third Current Risk Rating | Text |
Enter the current risk rating (e.g., a short label or score) for the third listed dimension/subdimension.
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| Third Dimension/Subdimension | Text |
Enter the dimension or subdimension name or code for the third listed item in this problem's dimensions/subdimensions. Fill only if 'Third Dimension - Dimensional Driver: Yes' is 'Yes'.
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| Third Dimension - Dimensional Driver: Yes | Checkbox |
Check this box if the dimensional driver for the third listed Dimension/Subdimension is present (answer = Yes).
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| Third Dimension/Subdimension and Risk Rating | ||
| Third Risk Rating | Text |
Provide the current risk rating for the third item.
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| Third Dimension/Subdimension | Text |
Enter the third dimension or subdimension.
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| Third Objective and Action Steps | ||
| Third Objective Action Step A | Text |
Please describe the first action step for the third objective.
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| Third Objective | Text |
Please provide a detailed description of the third objective.
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| Third Objective Action Step B | Text |
Please describe the second action step for the third objective.
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| Third Objective Action Step C | Text |
Please describe the third action step for the third objective.
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| Third Objective Action Step A | Text |
Enter the first action step for the third objective.
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| Third Objective | Text |
Enter the third objective for this problem.
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| Third Objective Action Step B | Text |
Enter the second action step for the third objective.
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| Third Objective Action Step C | Text |
Enter the third action step for the third objective.
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| Third Objective Action Step A | Text |
Enter the first action step for the third objective.
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| Third Objective | Text |
Enter the third objective.
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| Third Objective Action Step B | Text |
Enter the second action step for the third objective.
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| Third Objective Action Step C | Text |
Enter the third action step for the third objective.
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| Third Subdimension Row | ||
| Third Subdimension — Name | Text |
Enter the short name or label of the third subdimension (a brief phrase identifying which subdimension this row refers to).
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| Third Subdimension — Risk Description | Text |
Provide a concise description of the patient’s risks, concerns, or relevant clinical issues specific to the third subdimension. Fill only if 'Third Subdimension — Name' is 'Yes'.
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| Transition Barriers | ||
| Transition Barriers — Description | Text |
Describe any barriers to transitioning the patient to a less intensive level of care (for example: housing, transportation, childcare, financial, legal, or medical obstacles), providing relevant details and circumstances.
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| Treatment Plan Dates (initial and updated) | ||
| Initial Treatment Plan Date | Date |
Enter the date when the initial treatment plan was created or signed.
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| Updated Treatment Plan Date | Date |
Enter the date when the treatment plan was most recently reviewed or updated.
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| Trusted Support Persons | ||
| Trusted Support Persons List | Text |
Provide a list of individuals you trust to support you if you are at risk.
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| Warning Signs for Seeking Support | ||
| Warning Signs for Seeking Support | Text |
Please list the specific warning signs that indicate you are at risk and that you should reach out for support.
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