Case Management Final Work

Paul R.
Weatherly Updated by JI 11/2013

Cs Mgmt ALDAC 108

Patient/Individual Record Cover Sheet

Patient/Individual Name:Click here to enter text.

ID number: Click here to enter text.

Student Name: Click here to enter text.

Paul R. Weatherly Updated by JI 11/2013
Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual FileForm / File Content Check List

Patient/Individual Record Check List

Patient/Individual Record Cover Sheet
Patient/Individual Record Check List
Signature Authentication List
Intake Form
Screening Form
BioPsychSocial Assessment Form
HIV/AIDS Brief Risk Assessment Form
Diagnostic Summary
Master Problem List
Treatment Plans
Progress Notes
Discharge Summary
Continuing Care Plan
Consent for Release of Confidential Information
Patient/Individual Related Data
Counselor Disclosure Statement
Commitment to maintain Confidentiality
Patient/Individual Rights
Patient/Individual Disclosure Information
Treatment Rules and Expectations
Service Contract
Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Signature Authentication (Example)
Signature Authentication List
Name (Print) Title Credential Signature
Doris Cole
__
CM BCS Doris Cole

__ __ __ __

__ __ __ __

__________________ _______ _____ ______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

___________________ __________ __________ _______________________

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Intake
Date: ___4/14/14
Name: Sherman ________ ______Peabody
First Middle Last Nickname
Home Phone (000)-000-5000
Address: _197 Place S.E.__________
Street * PO Box Apartment #
Millcreek WA. 67219________________
City State Zip Code
Work Phone (500)-500-5005
Date of Birth: 04/01/97
Month/Day/Year
Drivers License or ID # ___ State: _WA_ Age: 20__
Social Security #: ___ Gender: x Male Female
Physician: Dr. Kevin Costner___
Name Location
Phone (_206-206-2006__)_
Personal Contact: Ellen Peabody___________
Name Relationship Location
Phone (425-254-0004)_
Next of Kin: ___Mother__Concrete WA.______________
NameRelationshipLocation
Phone (425-254-0004)_
Insurance Co. _Rubblestone.Com_
Name
Pre-Authorization
x Yes No
Phone (206-206-2066)_
Group Number
12345678910
Subscriber # 405 Subscriber Name _/___

Primary payment Source For Treatment xInsurance Private Pay
Medicare Title XIX
Referral Source
/ Attorney/Court/Probation
Name: _/____
School
Name: __/____
/ Yellow Pages
Substance Use DisorderAgency/Detox
Name: Colefacts Recovery Clinic
Mental Health Counselor
Name: ___/___
/ Family Member
x Physician or Hospital
Name:Dr. Kevin Costner
Native American Tribe
Name:___/___
/ Friend
x Insurance Co./Managed Care
Name:Rubblestone.Com
Other
____/___
/ Former Client/Alumni
x Employer/EAP/Union
Name: Foghorn Leghorn
/ re-Admit/Relapse
Presenting Problem: Sherman dosent believe his has a problem.
What substances is the Patient/Individual currently using, how much is being used and when was the last date of
use? Cannabis. He smokes 2.5 grams a day. He last smoked today on his lunch break 4/14/14.
Appointment for Evaluation: Date 04/15/14 Time __1400 A.M.__AM/PM
Patient/Individual Number:321456

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Screening
1.Can you read and write? List last grade completed in school
Click here to enter text.
2. What is the problem that brought you here today?

3. What special needs or concerns should the staff be aware of your visit today?
4. What is the impact of the problem on your life?
5. Why does this problem continue in your life?
6. What have you tried to address the problem?
7. Ideally, what would you like to happen?
8. What do you think might bring about this preferred solution?
9. What do you think supports or inhibits this solution?
10. What are you willing to do to find a solution?
11. What do you want from us?
12. What are the next steps we need to take?
13. List all the drugs and alcohol (prescription, over-the-counter, illegal) you have used in the
last thirty days and the last day you used them.
Cs Mgmt ALDAC 108

14. Do you have legal or employer problems related to substance use? Explain
15. Have you ever been the victim or the perpetrator of a violent crime or charged with domestic
violence? Explain
16. Have you ever been hospitalized or seen a counselor for emotion al problems?
17. Do you have a history of suicidal ideations or attempts? List the number of times and
outcomes.
18. Do you have current thoughts of harming yourself or a current plan for harming yourself?
19. Do you have a history of eating disorders or self-mutilation? Explain
20. Have you ever attended any recovery support groups or 12-step programs? Explain
21. Do you have a history of military service and any combat experience? Explain
22. Do you have reliable transportation? Explain
23. Do you have a place to live or are you homeless? Explain
24. Do you require referral for services other than treatment for Substance Use Disorder?
Explain
25. Do you have a history of mental illness? Explain
Patient/Individual Name:Click here to enter text.
Patient/Individual Signature:Click here to enter text.
Name of Patient/Individual Assistant:Click here to enter text.
Date:Click here to enter text.
Patient/Individual ID Number:Click here to enter text.

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/BioPsychSocial Assessment
This is an example of a chemical use disorder assessment tool. It is divided by ASAM dimension and is
designed to help students learn how to use assessment tools for appropriate Individual placement in the
continuum of care. It is not designed for reproduction as an agency assessment tool.
Patient/Individual Name: ____
Dimension 1
Drug and Alcohol Use History

Substances

Age
when
first
used

Age of
first
regular
use
During
heaviest
using
period,
how often
used
During
heaviest
use period,
amount of
use per
day
Route of
Administration
(Oral, smoke,
nasal, inhale, IV
or IM)

Date of last use
Alcohol
Beer
Wine
Distilled Spirits
Cannabis
Marijuana
Hashish
Hash Oil or Extract
Hallucinogens
LSD
Psilocybin
Ecstasy
Amphetamines
Crystal
Crank
Prescription
Cocaine
Crack Cocaine
Opiates
Opium
Heroin
Codeine
Prescription Drugs

Inhalants

Over-the-Counter

Nicotine
Caffeine
Other Drugs not
listed

Substance of Choice 1. 2. 3.
Describe pattern of use:
Cs Mgmt ALDAC 108

Have you ever used substances upon awakening? Yes No How often? ____
Have you ever used substances to relieve the effects of hangover? Yes No How often? ___
Have you ever been hospitalized for alcohol/drug related problems? yesNo How often? ___
Have you ever experienced a seizure, delirium tremens or hallucinations (auditory, visual or
tactile) when you stopped using substances? Yes No Explain: ___
Is the Patient/Individual experiencing any of the following?
Nausea or vomiting Auditory disturbances Agitation
Tremors Visual disturbances Aggression
Hot and/or cold sweats Anxiety Headaches
Tactile disturbances Unrealistic fears Disorientation
Constipation Bone aches and pains Restlessness/pacing
Mood swing cycles Number of cycles/24 hours_____

Tired or fatigued

Have you ever had a history of withdrawal symptoms that required hospitalization or medical
monitoring? Yes No How often? ____
Have you used any drug intravenously in the past thirty days? Yes No When? _____
Have you used barbiturates or benzodiazepines in the last thirty days Yes No When? ____
Are you presently taking any medication ( prescription or over-the-counter)? Yes No
Condition? ____ Medication Type?______ Explain: ___
Do you have any difficulty sleeping i.e. getting to sleep, staying asleep, early awakening w/o
being able to get back to sleep? Yes No Explain: _____

Dimension 2
What is the general condition of your health? ____
Have you had any major illnesses in the past? Yes No Explain: ___
Name of your physician? _____ Phone ( ____)____
Do you have any allergies? Yes No Explain: ____
When was the last time you saw a doctor? _____ Why? ______
When was your last physical exam? _____
Are you sexually active? Yes No Safe sexual practices? Yes No
Have you have any problems with impotence? Yes No Explain: _____
Do you use birth control? YesNo Current method or type? ______
Have you ever been pregnant? Yes No Miscarriages? Yes No
Is there any likelihood you are currently pregnant? Yes No How long? ____
What is your current weight? ___ Height __
Have you or anyone in your family ever been diagnosed as having any of the following?
You Family None Problem You Family None Problem
Alcoholism Loss of Appetite
Anemia Mental Illness
Asthma Morning Nausea
Cirrhosis Night Sweats
Depression Numbness in extremities
Diabetes Panic or anxiety attacks
Cs Mgmt ALDAC 108

Drug Addiction Pancreatitis
Delirium Tremens Recurrent Diarrhea
Fainting Seizures
Fatty Liver Shaking
Esophageal Reflux Significant weight loss or
gain
Head Injury Sleep problems
Headache or Migraine Suicide
Heart problems TB
Heartburn or Gastritis Ulcers
Hepatitis Use of Antabuse or trexan
High Blood Pressure Use of Prescription Drugs

How many times have you been hospitalized in the past five years? ___When? ___
Explain: _____
How many times in the past five years have you been to the Emergency Department?_____
When?______
Explain: _____
How many days have in the past five years have you used sick leave or called in to work sick? _
Explain: ___
Have you been seriously injured in the past five years? Yes No Explain: ____
Yes No
Have you ever: Had any fractures or dislocations to your bones or Joints

Been injured in a traffic accident?

Injured your head?

Been injured in an assault or fight (not sports injuries)?

Been injured while under the influence of alcohol or drugs?

Dimension 3
Have you ever been hospitalized or treated on an outpatient basis by a counselor, therapist or
doctor for emotional and/or related problems? Yes No Explain: _____
Have you ever tried to harm another person? Yes No Explain: ______
Have you ever tried to harm yourself? Yes No Explain: _________
Have you ever thought about suicide? Yes No Explain: _________
Do you have a current plan? Yes No Explain: ______
Have you ever attempted suicide? Yes No Explain: ______
Do you have a history of depression? Yes No Explain: ____
Have any of your family members committed suicide? Yes No Explain: ____
Have you experienced the any significant loss i.e. death of a family member, friend, pet or
colleague, divorce, job loss, freedom due to illness in yourself or family member? Yes No
Explain: _____
Are you comfortable with your weight? Yes No Explain: ____
Cs Mgmt ALDAC 108

Have you ever engaged in binging, purging, laxatives, fasting, diet pills or excessive dieting?
Yes No Explain: _____
How many times a day do you eat? __Meals __Snacks Explain: ____
Has anyone ever expressed concern to you regarding your eating habits or relationship with
food? Yes No Explain: ____
Have you ever taken drugs to control your weight or enhance your body i.e. diet pills, anabolic
steroids? Yes No Explain: _____
Have you ever been diagnosed with Post Traumatic Stress Disorder, Anxiety Disorders,
Obsessive/Compulsive disorders, Oppositional Defiance disorders, Attention Deficit
Hyperactivity disorders or any type of mental illness i.e. paranoia, schizophrenia ? Yes No
Explain: _____
How would you describe your self-esteem?Click here to enter text.
Marital Status Since Number of Times
Single (Never Married)

Married
_____ ___
Separated
_____ ___
Divorced
_____ ___
Widowed
_____ ___
Children
Gender Age Person Living With
_____ ____ ________
_____ ____ ________
_____ ____ ________
_____ ____ ________

Number of brothers___ sisters___? Where are you in the birth order? ___
Where were you born? _____Raised? ____
Are you currently employed? Yes No Explain: ______
How many jobs have you have in the past ten years? __ Explain: ____
Do you get along with your family? Yes No Explain: _____
Do arguments or fights with family members ever get violent? Yes No Explain:____
Years of education: Click here to enter text.1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Level completed: None GED HS Diploma Vocational Associates BA/BS MA PhD
Are you currently enrolled in school? Yes No Grade: _____
Average grades this year: ___ Average grades two years ago:_____
Favorite class: ______
Goals after school is completed: _____
Current extracurricular activities: Yes No Explain: _____
Past extracurricular activities: Yes No Explain: _____
How do you rate your English
reading/writing skills?
Good
Have you ever been diagnosed with
a learning disability or placed in a
special education class?
Yes
Fair No
Poor

Do you have any current legal problems? Yes No Explain: ____
Cs Mgmt ALDAC 108

Do you have a history of legal problems? Yes No Explain: ____
Current Legal Problem: _____ Date of Offense ____ BAL ____
Court _____ Judge ____ Case # ___
Court ______ Judge ____ Case # ___
Next court date____ Case status ____
Attorney name_____ Phone (____)______
Address ________
Probation Officer _____Phone (____)______
Address _____
Outstanding warrants: Yes No Explain: ___

Dimension 4
What do you think the term recovery means? ___
Have you ever had a history of blackouts? Yes No How many? ___
Have you ever used more than you intended? Yes No How often? ___
Do you have to use more in order to achieve the desired effect? Yes No
Do you achieve desired effect without increasing the amount you use? Yes No
Have you ever used for periods of time extending beyond twenty-four hours? Yes No How
often? __
Have you ever needed noticeably increased amounts of alcohol or other drugs to achieve
intoxication or desired effect? Yes No Explain: ___
Have you ever had a persistent desire or unsuccessful attempts to cut back or control your use of
alcohol or drugs? Yes No Explain: ___
Have you ever given up or lost important social, work or recreational activities because of
substance use? Yes No Explain: __
Have you ever had a physiological or psychological condition that you knew would be
exacerbated or made worse by the use of substances and continued to use? YesNo Explain:
___
Has anyone ever expressed concern to you or others about your substance use? Yes No
Explain: __
Has your use of substances ever affected your work in any way i.e. missed work, late, poor
performance, warnings, etc.? Yes No Explain: __
Have you ever been fired or quit a job due to substance use? Yes No Explain: ____
Did you use substances before or during school? Yes No Explain any problems that you had
i.e. poor grades, missed classes/school, tardiness, etc. ___
Have you ever been suspended or expelled due to substance use? Yes No Explain: ____
Have you ever done anything while under the influence that you would normally not do? Yes
No Explain: ___
Have you ever hidden substances or sneak drinks or drugs? Yes No
Have you ever lied about your use? Yes No
Have you ever used alone? Yes No
Have you ever felt guilty or ashamed for being under the influence? Yes No
Cs Mgmt ALDAC 108

Have you ever gotten physically aggressive or assaultive while you were under the influence?
Yes No
Has anyone ever told you that your personality changes when you are under the influence?
Yes No
Have you ever sold alcohol or drugs?Yes No Explain: _____

Reason
for
Treatment
Type of Treatment i.e.
education groups,
outpatient, intensive
outpatient, residential,
detox
Location i.e.
agency, school,
hospital
name,etc.

Dates of
Treatment

Length of
Abstinence

Explain specifics about previous treatment experiences.______
What is your assessment of your alcohol and drug use and history? _____
Describe your current motivation for recovery. _____
Describe the circumstances regarding your need for a substance use evaluation.____
Do you have a spiritual belief system that works for you? Yes No
Describe your childhood religious or spiritual upbringing, traditions or experiences? ____
Have you ever been in the military? Yes No Branch ____ Dates __to__
Honorable Discharge?Yes No Combat? Yes No Rank? _____
Did you drink or use drugs in the military Yes No
Did you receive any demotions as the result of substance use? Yes No Explain: ___

Dimension 5
How much of day do you spend in activities to obtain substances, using substances and
recovering from the effects of your substance use? ____
Have you ever received education or treatment for alcoholism or drug addiction? Yes No
What is the longest period of time since you regularly started using substances that you have
been abstinent? __ When? ___ Why? _____
After a period of abstinence what events, incidents or reasons occurred to cause to return to using
substances? ______
Do you live in an environment where people use substances? Yes No
Where do you spend the greatest amount of your free time and be specific? ____
What kind of activities do you do there? _____
What kinds of activities do you do with your friends? ____
Do you have any none using friends or family members? Yes No How many? ___
What did you do last weekend? ______
Have you ever attended a meeting of Marijuana, Cocaine, Narcotics or Alcoholics Anonymous?
Yes No How long? _____Explain: ____
Have you ever gotten a home group? Yes No Sponsor? Yes No
Describe your history of relapse? ______
Do you have the ability to refuse the use of substances? Yes No
Cs Mgmt ALDAC 108

Dimension 6
With whom do you spend the most of your free time? ____
How long have you had these friends? _____
Have you ever been in a gang? Yes No How long? __ Are you in one now? Yes No
Where are you currently living? _____ Who with? __
Do any of the people you are living with use substances? Yes No To excess Yes No
Are they willing to stop using while you are in treatment? Yes No
Are your family and friends willing to participate in treatment? Yes No
Are your family members willing to attend meetings of Alanon or Naranon? Yes No

Financial Status
Good
Housing Status
Own
Fair Rent
Poor Homeless

Are you seeking Deferred Prosecution or Diversion? Yes No
What of the following environmental issues has the potential for affecting your recovery?
Employment Issues Living situation
Rural, suburban or urban location Childcare responsibilities
Domestic Violence Availability of medical care
Sexual or emotional abuse Location of Chemical Dependency services
Are your family and friends supportive of your efforts to be in recovery? Yes No

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/HIV/AIDS Brief Risk Intervention Assessment
(Example)
Ask yourself these questions

Have I engaged in any activity that would allow blood, semen or vaginal fluids of another
person to enter my body?
Examples:
Anal intercourse without a condom?
Vaginal intercourse without a condom?
Oral intercourse without a condom?
Intravenous (IV) drug use with an outfit that has been use by anyone else?
Yes
No

Continue only if you answered YES to any of the above

How likely is it that blood, semen or vaginal fluid that I was exposed to actually had the
HIV virus in it?

Examples:
Man who has sex with another an.
IV drug user.
Hemophiliac
Sexual partner of any of the above
Very likely or dont know
Not sure, but I dont think so
Not likely
Continue only if you answered Very likely or dont now

Where in the country did my high risk behavior(s) take place?

Risk is higher in areas where there have been more AIDS cases.
New York City, NY
San Francisco, CA
Los Angeles, CA
Other large urban area
When were my high risk contacts?
Except for blood product recipients, high risk acts that took place recently are usually riskier than those that
took place in the past.
Within the past ten years
Within the past five years
Within the past two years

How often have I engaged in high risk behaviors?
Risk increases with the number or frequency of high risk behaviors.

Never ----------------------------------------------------------------------------- Very Often
Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Diagnostic Summary (Example)

Patient/Individual Name: _____
Patient/Individual ID Number:____

General Individual Profile:______

Diagnosis:
_________

DSM V Criteria:
1. ________
2. ________
3. ________
4. ________
5. ________
6. ________
7. ________
8. ________
9. ________
10. ________
11. ________

Dimension 1:
___________
Level of Care: 0.51.02.12.53.33.53.74.0

Dimension 2:
_________
Level of Care: 0.51.02.12.53.33.53.74.0

Dimension 3:
__________
Level of Care: 0.51.02.12.53.33.53.74.0

Dimension 4:
_________
Level of Care: 0.51.02.12.53.33.53.74.0

Dimension 5:
__________
Level of Care: 0.51.02.12.53.33.53.74.0
Cs Mgmt ALDAC 108

Dimension 6:
_________
Level of Care: 0.51.02.12.53.33.53.74.0

*NOTE: ___

Overall Recommended Level of Care: 0.51.02.12.53.33.53.74.0

__________ ___________
Patient/Individual Signature Date Counselor Signature Date

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Master Problem List Example

Problem
Number
____ Problem:______
Date
Identified
____

Treat Refer Defer Date Resolved/Referred _____

Problem
Number
___ Problem:_______
Date
Identified
___


Problem
Number
____ Problem:______
Date
Identified
____


Problem
Number
____ Problem:_____
Date
Identified
____


Problem
Number
____ Problem:_____
Date
Identified
____


Problem
Number
____ Problem:____
Date
Identified
____


Problem
Number
____ Problem:________
Date
Identified
____

Treat Refer Defer Date Resolved/Referred _______
Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Treatment Plan (Example)

Patient/Individual Name: _______Level of Care: _____

Dimension: _____Problem Number: ____ Date Identified: ____

Problem Statement: _______

Goal: ________

Resources and Strengths: _______

Date Measurable Behavioral
Objectives
Time-Link-Means
Interventions/Methods
Date
Achieved
Updates/Resolution Counselor
Initials

Patient/Individual Signature: _______Date:____
Patient/Individual ID Number: ___
Counselor Signature: _____Date: ____ Page: ___
Cs Mgmt ALDAC 108

Bellevue College

Patient/Individual Name: ______Level of Care: ___

Dimension: ____Problem Number: ___ Date Identified: ____

Problem Statement: _______

Goal: ______

Resources and Strengths: _____

Objectives
Time-Link-Means
Date
Achieved
Initials

Patient/Individual Signature: _____Date:___

Cs Mgmt ALDAC 108

Bellevue College

Patient/Individual Name: _____Level of Care: ___

Dimension: ____Problem Number: ____ Date Identified: ____

Problem Statement: _____

Goal: ______


Objectives
Time-Link-Means
Date
Achieved
Initials

Patient/Individual Signature: _____Date:____
Patient/Individual ID Number: ____
Counselor Signature: _____Date: ____ Page: __

Cs Mgmt ALDAC 108

Bellevue College


Dimension: ____Problem Number: ____ Date Identified: ___


Goal: _____


Objectives
Time-Link-Means
Date
Achieved
Initials

Patient/Individual Signature: ____Date:____
Counselor Signature: _____Date: ___ Page: __

Cs Mgmt ALDAC 108

Bellevue College


Dimension: ___Problem Number: ____ Date Identified: ____


Goal: _______

Resources and Strengths: ______

Objectives
Time-Link-Means
Date
Achieved
Initials

Patient/Individual Signature: _____Date:____

Cs Mgmt ALDAC 108

Bellevue College

Patient/Individual Name: ______Level of Care: ___

Dimension: ___Problem Number: ___ Date Identified: ____

Problem Statement: ____

Goal: _____


Objectives
Time-Link-Means
Date
Achieved
Initials

Patient/Individual Signature: _____Date:__
Patient/Individual ID Number: ____
Counselor Signature: ______Date: ___ Page: __

Cs Mgmt ALDAC 108

Bellevue College


Dimension: ____Problem Number: ____ Date Identified: ___

Problem Statement: ______

Goal: ______

Resources and Strengths: ____

Objectives
Time-Link-Means
Date
Achieved
Initials

Patient/Individual Signature: ____Date:___ Patient/Individual ID Number: ____
Counselor Signature: ______Date: ___ Page: __

Cs Mgmt ALDAC 108

Bellevue College
Progress Note Form (Example)
Year: 20 Progress Notes
D T
TD
P

__________ ____
Patient/Individual Name Page Number Patient/Individual ID Number
Cs Mgmt ALDAC 108

Bellevue College
D T
TD
P

__________ _______

Cs Mgmt ALDAC 108

Bellevue College
D T
TD
P

______________ ___

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Discharge Summary (Example)

Discharge Summary
Patient/Individual Name:_____Phone: (____)___
Address: ______Admit Date: ____

Discharge Date: ___

Reason for Discharge: ___

Referral Source: ____

Initial Diagnosis: __________

Initial Assessment:
_________

Dimension 1:
_________

Dimension 2:
__________

Dimension 3:
__________

Dimension 4:
__________

Dimension 5:
__________

Dimension6:
__________

Statement of Progress:
__________

Legal Issues:_________
Probation Officer: ________ Phone: (____)_____

Prognosis:
___________

Continuing Care Appointment Location: ______
Cs Mgmt ALDAC 108

Time: _____
Counselor: ______

Continuing Care Recommendations:
Abstinence from all substances that affect the central nervous system.
Follow nutritional guidelines developed by ______
Attend minimum of 7 Twelve Step meetings per week
Contact Twelve Step sponsor minimum of one time per day
Exercise on a regular basis i.e. three times per week
__________

Counselor Signature:________ Date:____

CC:
_________

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Continuing Care Plan (Example)
Continuing Care Plan
1. How many 12-step or community based sober support meetings do you plan on attending per
week? ___
2. List meetings by name, location and time to attend on each day of the week.
Monday: ______
Tuesday: _______
Wednesday: ______
Thursday: ________
Friday: __________
Saturday: _______
Sunday: ________
3. Emergency Contact Phone Number List
Sponsor: _________
________
________
________
________
4. List activities that can be done on a moments notice.
______
______
______
______
______
5. Describe plan for doing healthy recreational activities.
______
______
______
______
______
6. Describe plan for healthy nutrition.
_____
_____
_____
_____
_____

______ ___
Patient/Individual Signature Date

______ ___
Counselor Signature Date

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Consent for Release of Confidential Information (Example)
I, _________

First Middle Last

Authorize ______to disclose to: _____
Agency Name
_________
Name of person or organization to which disclosure is to be made
the following information: ___________
Nature of information, as limited as possible
The purpose of the disclosure authorized herein is to:
____________
Purpose of disclosure, as specific as possible

I understand that my records are protected under Federal regulations governing confidentiality of
Substance-related & Addictive disorders Individual records, 42 CFR, part 2, and cannot be
disclosed without my written consent unless otherwise provided for in the regulations. I also
understand that I may revoke this consent at any time except to the extent that action has been
taken in reliance on it, and that any event, this consent expires automatically as follows:
_______________
Specification of the date, event or condition upon which this consent expires

The following information will be released in the following form(s):
written verbal audio video electronic (including fax) other_____

For a minor, both participant and parent or guardian must sign this release



Parent or Legal Guardian Signature Date

Counselor Signature
Date

Patient/Individual ID Number

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Patient Related Data Worksheet

List minimum of five (5) types of documents that are examples of client related data.

1. ____
2. ____
3. ____
4. ____
5. ____
Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Counselor Disclosure Statement (Example)

Counselors practicing counseling for a fee must be registered or certified with the Department of
Licensing for the protection of the public health and safety. Registration of an individual with the
Department does not include recognition of any practice standards, nor necessarily implies the
effectiveness of any treatment. The following information is required to be provided prior to
commending treatment.

Treatment Philosophy:
___________

Fees and Billing Practices: ____________

One to One Counseling ___
Group Counseling ___

Counselor Education and Training:
_________

Counselor Information: (Name, Registration # and Credentials)
_________

The following conduct, acts, or conditions constitute unprofessional conduct
(1) The commission of any act involving moral turpitude, dishonesty, or corruption relating to
the practice of the person's profession, whether the act constitutes a crime or not.
(2) Misrepresentation or concealment of a material fact in obtaining a license or in
reinstatement thereof;
(3) All advertising which is false, fraudulent, or misleading;
(4) Incompetence, negligence, or malpractice which results in injury to an individual or which
creates an unreasonable risk that an individual may be harmed.
(5) Suspension, revocation, or restriction of the counselor's license to practice any health care
profession by competent authority in any state, federal, or foreign jurisdiction, a certified copy of
the order, stipulation, or agreement being conclusive evidence of the revocation, suspension, or
restriction;
(6) The possession, use, prescription for use, or distribution of controlled substances or legend
drugs in any way other than for legitimate or therapeutic purposes, diversion of controlled
substances or legend drugs, the violation of any drug law, or prescribing controlled substances
for oneself;
(7) Violation of any state or federal statute or administrative rule regulating the profession in
question, including any statute or rule defining or establishing standards of individual care or
professional conduct or practice;
(8) Failure to cooperate with the disciplining authority by:
(a) Not furnishing any papers or documents;
Cs Mgmt ALDAC 108

(b) Not furnishing in writing a full and complete explanation covering the matter contained in
the complaint filed with the disciplining authority;
(c) Not responding to subpoenas issued by the disciplining authority, whether or not the
recipient of the subpoena is the accused in the proceeding; or
(d) Not providing reasonable and timely access for authorized representatives of the
disciplining authority seeking to perform practice reviews at facilities utilized by the license
holder;
(9) Failure to comply with an order issued by the disciplining authority or a stipulation for
informal disposition entered into with the disciplining authority;
(10) Aiding or abetting an unlicensed person to practice when a license is required;
(11) Violations of rules established by any health agency;
(12) Practice beyond the scope of practice as defined by law or rule;
(13) Misrepresentation or fraud in any aspect of the conduct of the business or profession;
(14) Failure to adequately supervise auxiliary staff to the extent that the practitioner's health
or safety is at risk;
(15) Engaging in a profession involving contact with the public while suffering from a
contagious or infectious disease involving serious risk to public health;
(16) Promotion for personal gain of any unnecessary or inefficacious drug, device, treatment,
procedure, or service;
(17) Conviction of any gross misdemeanor or felony relating to the practice of the person's
profession.
(18) The procuring, or aiding or abetting in procuring, a criminal abortion;
(19) The offering, undertaking, or agreeing to cure or treat disease by a secret method,
procedure, treatment, or medicine, or the treating, operating, or prescribing for any health
condition by a method, means, or procedure which the licensee refuses to divulge upon demand
of the disciplining authority;
(20) The willful betrayal of a practitioner-individualprivilege as recognized by law;
(21) The acceptance directly or indirectly by any person so licensed of any rebate, refund,
commission, unearned discount, or profit by means of a credit or other valuable consideration
whether in the form of money or otherwise, as compensation for referring patient/individuals to
any person, firm, corporation or association as set forth in RCW 19.68.030, constitutes
unprofessional conduct.
(22) Interference with an investigation or disciplinary proceeding by willful misrepresentation
of facts before the disciplining authority or its authorized representative, or by the use of threats
or harassment against any individual or witness to prevent them from providing evidence in a
disciplinary proceeding or any other legal action, or by the use of financial inducements to any
Patient/Individual or witness to prevent or attempt to prevent him or her from providing evidence
in a disciplinary proceeding;
(23) Current misuse of:
(a) Alcohol;
(b) Controlled substances; or
(c) Legend drugs;
(24) Abuse of a Patient/individual or sexual contact with a Patient/individual;
(25) Acceptance of more than a nominal gratuity, hospitality, or subsidy offered by a
representative or vendor of medical or health-related products or services intended for
Patient/Individuals, in contemplation of a sale or for use in research publishable in professional
Cs Mgmt ALDAC 108

journals, where a conflict of interest is presented, as defined by rules of the disciplining
authority, in consultation with the department, based on recognized professional ethical
standards.

Confidentiality: conversations between you and ______ staff
Name of Agency
members will not be disclosed without your written consent, unless such disclosure is
required or permitted by law. You will be participating in group therapy and _____
requests that you treat information obtained in the course of
Name of Agency
your group as confidential with the group itself. It is understood that despite such requests
of other Individuals by _____. This agency is unable to
Name of Agency
ensure the confidentiality of information imparted during group activities.

_____________

_____________

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Commitment to Maintain Confidentiality (Example)
As a condition of my employment or service relationship with ____
Agency Name
I commit and agree to be bound by the following:
I am bound by 42 CFR, Part 2 of the Federal Confidentiality Regulations and RCW chapter
70.96A.
I certify not too divulge, publish, mention, or otherwise make known to any unauthorized third
party, orally or in writing, any information concerning an Individual of__ other than
Agency Name
to another ___ staff member, except when:
Agency Name

a. I have an authorized consent for the release of such information from the patient.
b. I am reporting child abuse or neglect as per RCW chapter 26.44.
c. I am reporting information concerning a crime that is proposed to be committed.
d. Requirements of court orders, federal or state laws and regulations.

I will consult management for direction anytime I am unclear as to the interpretation of
confidentiality regulations or the legality of requests made of me for information.

I agree to be bound by procedures for safeguarding Individual information, including:
a. All charts, notes, and other written materials will be locked up when not in use.
b. Discussions regarding Individuals will be held in staff offices or in other palaces
providing assurance of privacy.
c. No privileged information, written or verbal, will be shared with other agencies,
professionals, friends or family members without prior written authorization from the
Individual.
d. I shall deny all requests for access to _____ Individual files by anyone
Agency Name
not employed by _____ and refer such requests to theAdministrator.
Agency Name

I understand that an unauthorized disclosure of Patient/Individual information or records may
subject me to civil action for damages of $1000.00 or three times the amount of actual damages
sustained by a willful release of confidential information under RCW Chapter 71.05.440, or state
and federal criminal prosecution in an amount federally of not more than $500.000 for a first
offense and not more than $5000.000 for each subsequent offense.

I understand my commitment to confidentiality and that these requirements do not cease at the
time I terminate my relationship with _____ I agree to be permanently
Agency Name
bound by this commitment and by the regulations on confidentiality henceforth.

Click here to enter text. Click here to enter text. Click here to enter text.
Employee signature Employee name Date

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Individual Rights (Example)
A Patient/Individual is entitled to:
A) Treatment without regard to race, color, creed, national origin, religion, sex, sexual
orientation, age, or disability, except for bona fide program criteria;
B) Reasonable accommodations in case of sensory or physical disability, limited ability to
communicate, limited English proficiency, and cultural differences;
C) Be treated in a manner sensitive to individual needs and which promotes dignity and self-
respect;
D) Protection from invasion of privacy except that staff may conduct reasonable searches to
detect and prevent possession or use of contraband on the premises;
E) Have all clinical and personal information treated in accord with state and federal
confidentiality regulations;
F) Have the opportunity to review their own treatment records in the presence of the
administrator or designee;
G) Have the opportunity to have clinical contact with a same gender counselor, if requested and
determined appropriate by the supervisor, either at the agency or by referral;
H) Be fully informed regarding fees charged, including fees for copying records to verify
treatment and methods of payment available;
I) Be provided reasonable opportunity to practice the religion of their choice as long as the
practice does not infringe on the rights and treatment of others or the treatment service. You
have the right to refuse participation in any religious practice;
J) Be allowed necessary communication:
i) Between a minor and a custodial parent or legal guardian;
ii) With an attorney; and
iii) In an emergency
K) Be protected from abuse by staff at all times, or from other patients/Individuals who are on
agency premises, including:
i) Sexual abuse or harassment;
ii) Sexual or financial exploitation
iii) Racism or racial harassment; and
iv) Physical abuse or punishment.
L) Be fully informed and receive a copy of counselor disclosure requirements established under
RCW 18.170.060;
M) Receive a copy of Patient/Individual grievance procedures upon request; and
N) In the event of an agency closure or treatment service cancellation, each patient must be:
i) Given thirty day notice
ii) Assisted with relocation;
iii) Given refunds to which the person is entitled; and
iv) Advised how to access records to which the person is entitled.

______ _____
Patient/Individual Signature Counselor Signature

______ ___
Patient/Individual ID Number Date
Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Patient/Individual Disclosure (Example)

The Patient/Individuals consent to release information must be in writing and may be revoked at
any time by the Individual with the exception of consents regarding disclosures for court ordered
treatment.
Disclosures may be made without the Patient/Individual consent under the following
circumstances.
1. To medical personnel as necessary to meet a medical emergency
2. To those qualified to conduct research, management audits, financial audits, or program
evaluation
3. Appropriate court order after assessing good cause and weighing public good against
injury to the Patient/Individual
4. mutual exchange of information between the armed forces and the health care
components of the Veterans Administration
5. Between program staff in a program or administrative entities directly related to the
program for the purposes of providing treatment services
6. Criminal actions related to crime committed on the premises of the treatment agency or
program
7. Suspected child abuse and/or neglect
8. Suspected elder abuse and/or neglect
9. In the case of a minor parents may be notifies regarding reimbursement for treatment
services or if the minor is sufficiently incapacitated to make rational choices due to
physical/mental condition or when is a potential threat to life or well-being.

____ ____ ________________________

____ ____

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Treatment Rules and Expectations (Example)

In order for Patient/Individuals to have the opportunity to get the most benefit out of their
treatment experience the following rules and expectations have been developed in order to
create a pleasant, safe and non-judgmental treatment atmosphere.
1) No use of alcohol or other drugs on property.
2) Be on time for all appointments
a) If you are five minutes late for 1:1 or group appointment will be considered missed
and you will be considered out of compliance with treatment program.
b) If you will miss an appointment you must give 12 hour notice by telephone.
c) Missing three or more scheduled appointments without written permission will
constitute being out of compliance with treatment guidelines
3) Be respectful of peers and staff members i.e. refrain from name calling or other forms
of verbal harassment
4) Violent or threat of violent behavior is forbidden and police will be notified.
5) All weapons must be left in vehicles or at home.
6) Complete all treatment assignments and follow through on all referrals in a timely
manner.
7) Romantic relationships with staff members are strictly forbidden and strongly
discouraged between peers.
8) Use of nicotine products is strongly discouraged; however, if a Patient/Individual needs
to use nicotine products they are to be used in designated area outside.
9) Do not leave vehicles parked in parking lot overnight.
10) All fees must be paid on the due date or scheduled appointments will be cancelled and
the Patient/Individual found to be out of compliance with treatment program.

_____ ______

_____ ______

Cs Mgmt ALDAC 108

Bellevue College
Mock Patient/Individual File Form/Service Contract (Example)

_______
Name of Agency
I, ______voluntarily agree to enter ______for the
Patient/Individual Name Name of Agency
treatment of Substance-related & Addictive disorders. I, further agree to follow all rules and
regulations in this facility and agree that services for Substance Use Disorder Treatment may be
suspended, denied or refused by myself or the provider of services. In addition, I agree to pay all
fees incurred in the delivery of Substance Use Disorder Treatment services.
Schedule of Fees
1. One to One Counseling: $______
2. Group Counseling: $______
3. Documentation:
a. Evaluation Reports: $______
b. Court Reports: $______
c. Attorney Letters: $______
d. Probation Reports $______
e. Copies of Reports $______
4. Testing (Urinalysis) $______

I recognize that failure to follow through on paying for the cost of Substance Use Disorder
treatment may result in the termination of treatment and referral of my account to a collection
agency. In addition, failure to pay will result in notification of all authorities of your failure to
comply with expectations regarding the completion of treatment.

____ ____ _____
Patient/Individual Signature Date Patient/Individual ID Number

____ ____

Case Management Final Work

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Weatherly Updated by JI 11/2013

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