Sud 48 Hour Notification And Initial Treatment Plan
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1(Please include a copy
fax: 844-231-7948
of the LOCADTR3
Report with this form)
email:
SUD 48 HOUR NOTIFICATION
and INITIAL TREATMENT PLAN
Patient Information
Provider/Agency Name:
Patient Name:
Site Address:
/
/
Date of Birth:
Case Manager & Phone #:
Health Plan:
NPI #:
Member ID:
Tax ID:
Commercial
Medicaid/Essential
Diagnosis:
Date of Admission:
/
/
Detox Initial Treatment Plan
Adhere to OASAS approved detoxification taper/protocol.
Medication(s)
Planned Taper Duration:
Initial Discharge Plan
Inpatient
To home
Residential
Outpatient
Other:
Medical Stabilization:
Date of Assessment:
/
/
Med Orders:
Psychiatric stabilization:
Date of Assessment:
/
/
Med Orders:
Rehab Initial Treatment Plan (check all that apply)
Individual
Coping skills building to improve emotional
regulation, self-soothing
Group
Facilitate engagement with others – social skills
Family
to support recovery
Skills/Medication to reduce urges/craving
Education about, orientation to, and the
Motivational Interviewing to increase
opportunity to participate in, relevant
selfhelp groups
internal commitment
Assessment and referral services for patients and significant others
HIV and AIDS education, risk assessment, and supportive counseling and referral
Date of Medical consultation:
/
/
Date of Psychiatric consultation (as needed):
/
/
Signature
Date:
/
/
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Parent category: Medical