This form is not for claiming, service must be documented in a progress note in order to be claimed
SUD Treatment Plan
Client:
InSyst #	Last Name	First Name
Services were provided in:	by ☐ interpreter or ☐ clinician
STAFF INFORMATION
Agency:	RU:
Primary Counselor/LPHA:
SUD PLAN INFORMATION
Episode Opening Date:	Plan Dates - from:	to:
Plan Type:	☐ Initial (new to this RU or client).
For RES initial plan is due 10 days from EOD. NTP 28 days from EOD. All other SUD programs, 30 days from EOD.
☐ Update (90 day or change to current plan)
Date of previous plan:	Next scheduled plan update due date:
Primary Included SUD ICD-10 Code:
Primary Included SUD DSM-5 Name:
Additional Diagnosis ICD-10 Code:
Additional Diagnosis DSM-5/ICD-10 Name:
MY OVERALL STRENGTHS
INDIVIDUAL/FAMILY STRENGTHS TOWARD OVERCOMING BARRIERS AND ACHIEVING DESIRED RESULTS:

Treatment Plan Challenges/Problems, Goals, and Actions Steps on next page. Copy additional pages as needed.

ASAM Dimension	Problem / Challenge (Identified during intake or since previous plan)	Goal (If deferred indicate and provide reason)	Action Steps / Interventions	Target Date	Date Goal Met (To be completed as goals are met)

TYPE AND FREQUENCY OF SERVICES
TYPE	FREQUENCY	DURATION
☐ Individual Counseling
Description of services to be provided:
☐ Group Counseling
Description of services to be provided:
☐ Collateral
Description of services to be provided:
☐ Family Therapy
Description of services to be provided:
☐ Medication Services
Description of services to be provided:
☐ Patient Education
Description of services to be provided:
☐ Group Multi-Family Counseling
Description of services to be provided:
☐ Case Management: Care Coordination
Description of services to be provided:
☐ Case Management: Service Coordination
Description of services to be provided:
☐ Withdrawal Management - Observation
Description of services to be provided:
☐ Withdrawal Management - Medication
Description of services to be provided:
☐ Recovery Service Monitoring SAA
Description of services to be provided:
☐ Residential Day
Description of services to be provided:
DISCHARGE PLAN
DISCHARGE PLAN (Readiness/Time Frame/Expected Referrals, etc.):
ADDITIONAL COMMENTS
(Client, Provider, Family, etc. and provide name and title of other Treatment Team members):
The beneficiary meaningfully participated in the preparation of this plan? ☐ Yes ☐ No , if no explain below:
☐	Plan was discussed in primary language:
☐	Individual/Family was offered a copy of this plan:
☐	Individual/Family participated in the development of, and agreed to plan on date:
☐	Treatment team member participated in the development of the Plan on date:
☐	Provider attests that individual signed the plan on date:
☐	Provider attests that legal representative (Parent, Legal Guardian, Conservator, etc.) signed or verbally accepted this Plan on this date due to Individual inability to sign on date:
☐	Individual/Family verbally accepts this plan but not able to sign on this date (explain below):
☐	Individual/Family declines to sign (explain below) on date:
☐	See progress note describing development of the plan with Individual/Family, dated:
Comments:
TREATMENT TEAM
☐	LPHA/SUD Counselor
☐	Physician
☐	Psychiatrist	☐ Client is being treated by a non-BHCS psychiatrist
☐	Program Supervisor
☐	Medical Director
☐	Other
This plan also sent to:
Client Signature	Printed Name	Date
Counselor Signature	Printed Name/Credentials	Date (this is the plan date)
MD/LPHA Signature*	Printed Name/Credentials	Date
*MD/LPHA co-signature required when plan is completed/signed by SUD counselor. Co-signature is required within 15 days of counselor signing the plan and within plan due date requirements.