20-3D

Name: ________________________________ Number: ________________ Plan Start Date: ___________________

Admission Date: __________________ Program Type_________________ Primary Counselor: ________________

Problem: Participant has a need to complete the CCA Substance Use Disorder Treatment Program based on
bio-psycho-social assessment

Long-term Outcome/Goals: Complete all necessary assessments related to the treatment program

OBJECTIVES/INTERVENTIONS:

Date IM/Counselor Objectives Target Date Achieved Date/

Initial
1 Client will attend first group session and complete the
assessment surveys: CTS, MOT, PSY, SOC.
2 Client will submit to intake urine drug screen.

3 Client will demonstrate a verbal understanding of all

group rules and commit to participating by these rules.
4 Client will attend individual session to develop the master
treatment plan
5 Client will acknowledge receipt of RDAP participant
handbook and demonstrate understanding of contents.

Obj # Methods/Interventions (Services) Frequency

Counselor will provide all the necessary assessments, score them and place documentation in the
1 chart One time
Counselor will administer or arrange for the drug screen at intake and documentation of the results
2 in the participant's file. One time
Counselor will provide the participant with the group rules and expectations and assure that the
3 participant understands these rules by verbal agreement. One time
Counselor will provide an individual session to develop the Master Treatment Plan with the
4 participant. One time
Counselor will provide client with a copy of the handbooks and review contents. Counselor will
5 assure that participant understands content by verbal agreement. One time

Inmate's Signature: _________________________________________________ Date: ___________________

Clinician's Signature: _______________________________________________ Date:___________________

Rudolph Kolder, AddictionTreatmentCounselor,MA

Treatment Manager Signature: ________________________________________ Date:___________________

Vanessa Hernandez, MA, ISAC,LAC

Proprietary Information – Not for Distribution – Copyrighted – Property of CCA 6/10/15