Case Study: Marge Treatment Plan Template

Stated as broad desirable outcome that will be broken down into short-term goals and objectives. Usually, one long-term goal will be adequate for first year.

Example:

1.      John will remain abstinent from use of heroin and all other mood-altering substances and behaviors for one year as demonstrated by negative random drug screens and self-report)

Example:

John will successfully complete residential treatment.

1.      Short-Term Goal 1

Statements of what client will do to achieve short-term goal. Stated in measurable, behavioral terms

Example:

1.      John will attend and actively participate in all individual and group counseling sessions.

John will admit he has an addiction problem.

1.      Short-Term Goal 1: Action Step:  How objective will be carried out or accomplished

Example: Schedule one individual counseling session and five group counseling sessions weekly. John will complete Step One of the Twelve Steps

2.      Short-Term Goal 2: Action Step:

Objective, measurable desirable outcome with timeframe

Example:

1.      Staff and self-report of regular attendance and active participation in individual and group counseling sessions (30 days).

2.      Self-report to counselor and members of group sessions (30 days).

2.      Short-Term Goal 1

3.      Short-Term Goal 2

3.      Short-Term Goal 1: Action Step:

4.      Short-Term Goal 2: Action Step:

4.      Short-Term Goal 1

5.      Short-Term Goal 2

5.      Short-Term Goal 1: Action Step:

6.      Short-Term Goal 2: Action Step:

6.      Short-Term Goal 1

7.      Short-Term Goal 2

7.      Short-Term Goal 1: Action Step:

8.      Short-Term Goal 2: Action Step:

8.      Short-Term Goal 1

9.      Short-Term Goal 2

9.      Short-Term Goal 1: Action Step:

10.    Short-Term Goal 2: Action Step:

·       Substance(s) used and/or any addictive behaviors identified

·       Age of first use

·       Family history of addiction (chemical and/or behavioral)

·       Progression of use to current stage

·       Average frequency and amount over last six months

·       Other signs and symptoms of addictive use (e.g., blackouts, increased tolerance over time, physical withdrawals if use stopped)

·       Negative consequences experienced due to use

·       Previous attempts to stop on own and/or treatment history

·       Level of denial of problem (e.g., none, mild, moderate, severe)

·       Level of motivation to change on admission (i.e., low, moderate, high)

·       Any other current or past mental disorder or mental health problem

·       Signs, symptoms, course of disorder, and other pertinent information necessary to plan treatment

·       History of treatment or counseling

·       Pertinent current or past medical history related to or affected by addiction

·       Current medications (e.g., psychotropic and/or prescribed addictive medications)

·       Education

·       Work/career history including problems related to addiction

·       Current financial status

·       Current status of any existing legal problems

·       Socioeconomic status

·       Any cultural/ethnic factors influencing addiction and recovery

·       Social/leisure activities

·       Composition of immediate family

·       Description of roles identified for each family member

·       An explanation of the potential impacts of these roles on family members.

·       Include family in client’s treatment plan and a minimum of two resources that would be useful to them

·       Overview of ongoing assessment process to evaluate severity of the addiction, rule out the co-existence of other relevant problems, assist in treatment planning, and monitor progress (e.g., continued more detailed interviews with client and family members, observation, standardized assessment instruments).

·       Model(s) of treatment used. Rationale for use and strengths and weaknesses of chosen model(s)

·       Include benefits of choosing evidence-based practice as model of treatment

·       Model(s) of case management used. Rationale for use and strengths and weaknesses of chosen model(s)

·       Include benefits of choosing evidence-based practice as model of case management, Case Study: Marge Treatment Plan Template

·       Ways in which client’s spiritual needs might be addressed through case management referrals to community 12-step support groups or other spiritual resources

·       Dimension 1:

·       Dimension 2:

·       Dimension 3:

·       Dimension 4:

·       Dimension 5:

Projected level(s) of treatment after discharge from residential treatment over the next 12 months and an explanation of why this level(s) would be effective

·       Projected levels of treatment over next 12 months

·       Prognosis for response to treatment over next 12 months

·       What are your ethical responsibilities in working with addictions and cultural responsiveness?  Support your points with specific ethical standards and a plan for ongoing ethical and cultural responsiveness.

·       How will you keep up with trends related to best practices, integrating telehealth counseling, and any changes to laws or ethical standards? Support your points with the course learning resources and a specific plan to address these factors. Finally, discuss your personal and professional strengths that will support your practices and a plan for ongoing self-care.

Support your points with specific references to the Learning Resources and any additional sources you identify, using both in-text citations and references. It is strongly recommended that you include proper APA format and citations