The Addiction Counselor's Documentation Sourcebook: The Complete Paperwork Resource for Treating Clients with Addictions (Practice Planners)

243 Pages·2005·6.17 MB·English

by  James R. Finley

Addiction

The
Counselor’s

DOCUMENTATION
SOURCEBOOK
The Complete Paperwork Resource for
Treating Clients with Addictions
SECOND EDITION
James R. Finley
Brenda S. Lenz

John Wiley & Sons, Inc.

Addiction

The
Counselor’s
DOCUMENTATION

SOURCEBOOK

Addiction

The
Counselor’s

DOCUMENTATION
SOURCEBOOK
The Complete Paperwork Resource for
Treating Clients with Addictions
SECOND EDITION
James R. Finley
Brenda S. Lenz

John Wiley & Sons, Inc.
This book is printed on acid-free paper.
Copyright © 2005 by John Wiley & Sons, Inc. All rights reserved.
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ISBN 0-471-70381-8
Printed in the United States of America.
10 9 8 7 6 5 4 3 2 1
To our spouses, who walk with us every day and are our havens;
to our parents, who came before us and have showed us the way in so many things;
to our children and grandchildren who will follow after us and yet also have much to show us;
to our colleagues, who join us in choosing this work;
and above all to the many clients with whom we have shared so many experiences, who have
given us so much, and who will continue to do so in the years ahead.

Contents
CD Contents ............................................................ xi
Introduction ............................................................. xv
Chapter One Precontact: Referral Forms ......................... 1.1
Form 1.1: Referral for Services........................................... 1.2
Form 1.2: Appointment Notification/Confirmation Letter.................. 1.3
Form 1.3: Referral and Treatment Compliance Follow-Up Letter.......... 1.4
Form 1.4: Thank You for Your Referral................................... 1.5
Form 1.5: HIPAA Notice of Privacy Practices............................. 1.6
HIPAA Privacy Authorization for Use and Disclosure
of Personal Health Information ................................ 1.8
Form 1.6: HIPAA—Client Sign-In Sheet.................................. 1.9
Chapter Two Intake and Assessment Forms ..................... 2.1
Form 2.1: Initial Client Information Fact Sheet............................ 2.3
Form 2.2: Confidential Brief Health Information Form.................... 2.4
Form 2.3: Therapist Clinical Assessment.................................. 2.5
Form 2.4: Chemical Dependence Assessment Matrix...................... 2.11
Form 2.5: Substance Abuse Assessment Matrix........................... 2.13
Form 2.6: Acuity of Need/Level of Treatment Assessment Matrix......... 2.15
Form 2.7: Informed Consent and Payment Agreement for Services........ 2.17
Form 2.8: Authorization for Disclosure of Information.................... 2.18
Form 2.9: Client Rights and Limits of Confidentiality
Handout and Acknowledgment................................. 2.19
vii
Contents
Chapter Three Treatment Forms ................................... 3.1
Form 3.1: Behavioral Contract............................................ 3.3
Form 3.2: Contract against Suicide, Self-Harm, or Harm to Others ........ 3.4
Form 3.3: Client Input for Treatment Planning............................ 3.5
Form 3.4: Master Treatment Plan......................................... 3.6
Form 3.5: Treatment Plan Update/Revision Form ......................... 3.9
Form 3.6: Group Therapy Progress Note.................................. 3.10
Form 3.7: Individual/Family Therapy Session Progress Note.............. 3.11
Form 3.8: Telephone Contact Progress Note .............................. 3.12
Form 3.9: Therapeutic Materials Loan Record ............................ 3.13
Form 3.10: Eye Movement Desensitization and Reprocessing (EMDR)
Information Handout........................................... 3.14
Form 3.11: Eye Movement Desensitization and Reprocessing (EMDR)
Consent for Treatment......................................... 3.18
Form 3.12: Eye Movement Desensitization and Reprocessing (EMDR)
Progress Note ................................................. 3.19
Form 3.13: Recovery Program Meeting Review/Critique Form............. 3.21
Chapter Four Treatment Forms: Program Administration
Documentation ...................................... 4.1
Form 4.1: Client Encounter Summary Log Sheet.......................... 4.3
Form 4.2: Monthly Progress Note/Report................................. 4.4
Form 4.3: Recovery Program Attendance Verification Form............... 4.6
Form 4.4: Request/Referral for Extended Services ........................ 4.7
Form 4.5: Request/Referral for Additional Services....................... 4.8
Form 4.6: Request for Drug Screening by External Providers.............. 4.9
Form 4.7: Treatment Program Attendance/Completion Record ............ 4.10
Form 4.8: Certificate of Completion ...................................... 4.11
Form 4.9: Case Staffing Record........................................... 4.12
Form 4.10: Treatment Termination Warning ............................... 4.13
Form 4.11: Treatment Termination Notification............................ 4.14
Form 4.12: Treatment Discharge Summary................................. 4.15
Form 4.13: Request for an Accounting of Disclosures...................... 4.16
Form 4.14: Disclosure Tracking Log....................................... 4.17
viii