Substance Abuse Prevention And Control - Treatment Plan Form
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4SUBSTANCE ABUSE PREVENTION AND CONTROL
TREATMENT PLAN FORM
Mail:
Substance Abuse Prevention and Control
Website:
1000 S. Fremont Ave, Bldg. A9 East, 3rd Floor, Alhamabra, CA 91803
Fax:
(XXX) XXX-XXXX
To check submission status call: (XXX) XXX-XXXX
1. Name (Last, First, and Middle):
2. Date of Birth (MM/DD/YY):
3. Medi-Cal Identification Number:
5. Treatment Agency:
4. Primary Counselor's Name:
6. DSM-5 Diagnosis(es):
7. Is Patient's Physical Examination Result Available?
If yes, provide the date the physical exam was completed:
If no, provide the date of scheduled physical exam:
8. Assessment Date:
9. Updated Treatment Plan Date:
ASAM Dimensions: 1. Acute intoxication and/or Withdrawal Potential; 2. Biomedical Conditions and Complications; 3. Emotional, Behavioral or
Cognitive Conditions/Complications; 4. Readiness to change; 5. Relapse Continued Use, or Continued Problem Potential; 6. Recovery Environment
Severity: 0 - None; 1 - Mild, 2 - Moderate, 3 - Severe, and 4 - Very Severe.
PROBLEM # 1
10. Problem Statement:
11. Long-Term Goal:
12. Treatment Start Date:
13. Dimension:
14. Severity:
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15. Short-Term Goal(s) (SMART):
16. Action Steps:
17. Target Date:
18. Completion Date:
PROBLEM # 2
10. Problem Statement:
11. Long-Term Goal:
12. Treatment Start Date:
13. Dimension:
14. Severity:
0
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2
3
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15. Short-Term Goal(s) (SMART):
16. Action Steps:
17. Target Date:
18. Completion Date:
Client Name:
Medi-Cal ID:
This confidential information is provided to you in accord with State and Federal laws and regulations including but
not limited to applicable Welfare and Institutions Code, Civil Code and HIPAA Privacy Standards. Duplication of
this information for further disclosure is prohibited without the prior written authorization of the patient/authorized
Treatment Agency:
representative to who it pertains unless otherwise permitted by law.
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Treatment Plan Form
Revised 5/13/2016
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