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Substance Abuse Counsellor Template

Substance Abuse Discharge Summary

A professional Substance Abuse Counsellor template for healthcare professionals.
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Specialty

Substance Abuse Counsellor

Used

44 times

Type

Note

Last edited

22/11/2024

Created by

Anonymous

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About this template

The Substance Abuse Discharge Summary template is an essential tool for substance abuse counsellors to document a client's treatment journey and discharge plan. This template captures critical information such as client details, treatment summary, discharge reasons, and follow-up care plans. It ensures a comprehensive overview of the client's progress and provides necessary referrals and emergency contacts. The template also includes sections for medications, legal considerations, and client education, making it a valuable resource for clinicians in substance abuse treatment settings. This structured format aids in seamless transitions to outpatient care and supports ongoing recovery efforts.

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Client Details: - Name: John Doe - Date of Birth: 15 March 1985 - Client ID Number: 123456 - Admission Date: 1 September 2024 - Discharge Date: 1 November 2024 - Primary Contact: Jane Doe, Sister, +44 1234 567890 Summary of Treatment: - Primary Diagnosis: Alcohol Use Disorder, Co-occurring Disorder: Generalized Anxiety Disorder - Treatment Provided: Individual therapy, Medication-assisted treatment (MAT), Group therapy - Client's Response: Significant progress in managing anxiety symptoms, reduced alcohol consumption, occasional challenges with cravings Reason for Discharge: - Treatment goals met, client has developed coping strategies and is ready for outpatient care Discharge Instructions: - Referrals: - Outpatient therapy program at City Health Clinic - Follow-Up Care Plan: - Weekly therapy sessions, monthly check-ins with primary care physician - Emergency Contacts and Crisis Resources: - National Helpline: 0800 123 4567, Local Crisis Center: City Support Services Medications at Discharge: - Sertraline 50mg daily, Naltrexone 50mg daily - No changes to medication regimen during treatment Legal or Occupational Considerations: - Court-mandated treatment completed, report submitted to probation officer Client Education: - Key Topics: Relapse prevention, harm reduction, stress management - Materials Provided: Brochures on coping strategies, website links for support groups

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