Most of this type of documentation is collected during the admission or intake
process and may include:
1. Client name, address, etc.
2. Demographics, sex, race, employment, etc.
3. Referral source name.
4. Financial Information, income, insurance, etc.
5. Client rights and responsibility.
6. Informed consent for treatment (or involuntary order for treatment) Alternatively,
the release of info, drug testing, dated and signed by a witness.
7. Orientation to program services information,
8. Outcome measures.
9. Client placement Information.
Give this one a try later!
Administration Documentation. p142
, This is not something that begins when the client is ready to exist treatment; rather, it
is a process that occurs throughout treatment. It usually includes:
1. Referral source.
2. Presenting Problem and reasons for service.
3. Treatment goals/methods/outcomes.- The type of outcomes by the clients can vary
depending on treatment/service protocols, as well as the measures imposed by the
funding sources (grants, states, and insurances). Overall, outcomes pertain to the
person's ability to attain and sustain recovery, build resilience and work, learn, and
live, and participate fully in the community. Client outcomes are typically measured at
different time intervals through.
a. Treatment plan updates.
b. Conclusion of the primary treatment episode.
c. Prescribed follow-up points.
4. Condition of client served at the time of discharge.
5. Follow-up recommendations (continuing care and recovery support).
6. Signature, date, and counselor's credentials.
#1 and #2 both come from the assessment.
#3 and #4 both come from the treatment plan.
Give this one a try later!
Elements of Discharge Plan. p144
In general, clients must give written consent in a specified format before information
can be released to other parties/agencies. Also, most agencies have policies in place
in regards to who can release verbal and or written information from client records.
Subpena's and or court orders are sometimes received to release information, this
should be revealed to the supervisor immediately.
Give this one a try later!
process and may include:
1. Client name, address, etc.
2. Demographics, sex, race, employment, etc.
3. Referral source name.
4. Financial Information, income, insurance, etc.
5. Client rights and responsibility.
6. Informed consent for treatment (or involuntary order for treatment) Alternatively,
the release of info, drug testing, dated and signed by a witness.
7. Orientation to program services information,
8. Outcome measures.
9. Client placement Information.
Give this one a try later!
Administration Documentation. p142
, This is not something that begins when the client is ready to exist treatment; rather, it
is a process that occurs throughout treatment. It usually includes:
1. Referral source.
2. Presenting Problem and reasons for service.
3. Treatment goals/methods/outcomes.- The type of outcomes by the clients can vary
depending on treatment/service protocols, as well as the measures imposed by the
funding sources (grants, states, and insurances). Overall, outcomes pertain to the
person's ability to attain and sustain recovery, build resilience and work, learn, and
live, and participate fully in the community. Client outcomes are typically measured at
different time intervals through.
a. Treatment plan updates.
b. Conclusion of the primary treatment episode.
c. Prescribed follow-up points.
4. Condition of client served at the time of discharge.
5. Follow-up recommendations (continuing care and recovery support).
6. Signature, date, and counselor's credentials.
#1 and #2 both come from the assessment.
#3 and #4 both come from the treatment plan.
Give this one a try later!
Elements of Discharge Plan. p144
In general, clients must give written consent in a specified format before information
can be released to other parties/agencies. Also, most agencies have policies in place
in regards to who can release verbal and or written information from client records.
Subpena's and or court orders are sometimes received to release information, this
should be revealed to the supervisor immediately.
Give this one a try later!
