CENTER FOR FAMILY SERVICES - SUBSTANCE ABUSE SERVICES

TREATMENT PLAN
Client Name:

Initial

Counselor Name:__________________________

Review

Revised

Category: Drug Dependence / Withdrawal

Problem:

Date Identified:

Target Date:

Diagnosis:
Long Term Goal (Over 30 Days)
Short Term Goal (30 Days or Less)
Objectives (Measurable)
Progress Since Last Plan

Category: Biomedical Conditions / Complications

Problem:

Date Identified:

Target Date:

Date Identified:

Target Date:

Diagnosis:
Long Term Goal (Over 30 Days)
Short Term Goal (30 Days or Less)
Objectives (Measurable)
Progress Since Last Plan

Category: Emotional / Behaviorial

Problem:

Diagnosis:
Long Term Goal (Over 30 Days)
Short Term Goal (30 Days or Less)
Objectives (Measurable)
Progress Since Last Plan

Individual Treatment Plan for:

Category: Treatment Acceptance / Resistance

ID#

Chart #

Problem:

Date Identified:

Target Date:

Date Identified:

Target Date:

Diagnosis:
Long Term Goal (Over 30 Days)
Short Term Goal (30 Days or Less)
Objectives (Measurable)
Progress Since Last Plan

Category: Relapse Potential

Problem:

Diagnosis:
Long Term Goal (Over 30 Days)
Short Term Goal (30 Days or Less)
Objectives (Measurable)
Progress Since Last Plan

Category: Recovery Environment

Problem:

Date Identified:

Target Date:

Diagnosis:
Long Term Goal (Over 30 Days)
Short Term Goal (30 Days or Less)
Objectives (Measurable)
Progress Since Last Plan

Progress Since Last Plan:

Individual Treatment Plan for:

General Notes

ID#

Chart #

Patient Has Actively Participated in Treatment Plan Process and Agrees That It Meets Their Needs

Client Signature/Date
Counselor Signature/Date
Supervisor Signature/Date

I=Individual

G=Group

Service Codes
F=Family/Couples P=Psychoeducational

H=Homework

R=Referral