SUD Initial Treatment Plan (Person-Centered)

Substance Use Disorder Initial Treatment Plan

(Use person-centered, recovery-oriented, non-stigmatizing language throughout. Use the patient's preferred name and pronouns. For missing information, use standardized tokens: "Not assessed (reason)", "Unknown", "Patient declined", "Not applicable", or "Pending (expected date)". Do not infer agreement, abstinence, or legal requirements unless explicitly documented.)

Patient Name/DOB/MRN: [Patient preferred name], [Date of birth], [Medical record number] ([Pronouns])

Plan Effective Period: [Start date] through [Planned review date]

Level of Care/Program: [Outpatient / Intensive outpatient program (IOP) / Residential treatment / Opioid treatment program (OTP) / Office-based treatment / Partial hospitalization program]

Location/Author: [Program/site name], [Clinician name and credentials]

Primary Language/Interpreter: [Primary language]; Interpreter used: [Yes / No / Not needed]. (If yes, include interpreter name or ID and modality used.)

Diagnoses: [DSM/ICD codes with written descriptions for all substance use and mental health diagnoses]

Planning Participants and Consent Context

Participants: [Names and roles of all who participated in plan development] (Patient, clinician(s), peer specialist, family/supports invited by patient, guardian, care manager.)

Decision-making supports: [Supports used to elicit patient preferences] (Interpreter, supported decision-making, guardian involvement.)

Consent and release-of-information status: [Current consent status for information sharing] (Include any 42 CFR Part 2-compliant releases: what information, with whom, purpose, and expiration. Note any declines and alternatives offered.)

Collaboration statement: [Statement confirming collaborative development with patient] (If patient declined to participate or sign, document "Patient declined" with rationale and follow-up plan to revisit.)

Assessment Synthesis

Presenting concerns and patient-defined goals: [Patient's primary concerns and desired outcomes in their own words]

Substance use summary: [Substances currently used, pattern/frequency, quantity, route if relevant, last use dates, craving level if reported, prior treatment episodes and responses, withdrawal or intoxication risk status, overdose history] (Include only details explicitly available; do not infer.)

Co-occurring conditions: [Mental health conditions, medical comorbidities impacting care, pain conditions, pregnancy status if relevant]

Functioning and recovery environment: [Housing stability, employment/education, family/relationships, legal concerns, transportation, recovery supports, triggers and barriers]

Readiness and motivation: [Stage of change observations, motivational factors, ambivalence areas]

Standardized measures (baseline): [Assessment scores: PHQ-9, GAD-7, craving scale, other relevant scales, toxicology summary if obtained] (Treat toxicology as one data source among many; do not equate a single test with recovery status.)

Strengths, Preferences, and Recovery Capital

• Strengths/assets: [Skills, values, supportive relationships, prior recovery periods, interests, coping abilities]
• Treatment preferences: [Group vs individual], [In-person vs telehealth/hybrid], [Scheduling preferences], [Communication preferences]
• Medication preferences: [Openness or concerns about medications for substance use disorder and mental health] (Document preferences without presuming acceptance.)
• Cultural/spiritual considerations: [Cultural identity, spiritual practices, community preferences]
• Barriers needing accommodation: [Work schedule, childcare, transportation, literacy/language, accessibility, technology access]
• What matters most to the patient: [Patient-defined priority outcomes]

Safety and Risk Planning

Overdose Risk

(Complete when any opioid or sedative risk is present. If not applicable, state "No opioid or sedative risk identified.")

• Risk factors: [Identified factors: recent return to use, mixing substances, reduced tolerance, prior overdose, respiratory or liver disease, concurrent sedatives, using alone, fentanyl exposure]
• Naloxone status: [Prescription provided / Supplied on-site / Patient already has / Patient declined]; Training provided: [Yes / No]
• Safer-use counseling provided: [Topics addressed: avoiding using alone, test dosing, avoiding mixing with sedatives/alcohol, fentanyl contamination awareness, naloxone access]
• Overdose response instructions: [Emergency contact, naloxone administration steps, positioning, post-reversal monitoring, follow-up care plan]

Suicide/Self-Harm Risk

• Screening result and risk level: [Screen used and results]; Risk level: [None identified / Low / Moderate / High]
• Warning signs: [Personal warning signs the patient identifies]
• Internal coping strategies: [Activities or strategies the patient will try independently]
• Social supports: [Names/relationships and contact methods the patient agrees to use]
• Professional/crisis resources: [Clinic contact, after-hours line, local crisis team, 988 Suicide & Crisis Lifeline, 911]
• Lethal means reduction: [Means identified, steps to reduce access, responsible person, timeline]
• Follow-up plan: [Specific follow-up timeframe, responsible clinician, escalation steps]

(If no risk identified, document negative screening result. If not assessed, document "Not assessed (reason)".)

Other Safety Concerns

(Complete applicable sections; mark others "Not applicable.")

• Violence/victimization/domestic violence: [Concerns identified, resources and referrals offered, safety plan elements]
• Medical risks requiring monitoring: [Pregnancy status, infectious disease testing, withdrawal seizure risk, other conditions and monitoring plan]
• Mandated reporting: [Report made / Not applicable]; (If made: date, agency, reason, patient notified [Yes / No])

Relapse/Recurrence Prevention Plan

• High-risk triggers/situations: [People, places, feelings, events, times identified by patient]
• Early warning signs: [Cravings, thoughts, behaviors, mood or sleep changes]
• Coping strategies: [Specific skills the patient will use]
• Recovery supports to contact: [Names/roles and contact information for peer, sponsor, recovery group, supportive family/friend]
• Treatment re-engagement steps: [Who to call, how to access same-day/next-day care, expected response time] (Recurrence triggers plan reassessment and modification, not automatic discharge.)

Problem List, Goals, Objectives, and Interventions

(Prioritize: acute safety risks, high-severity substance use, co-occurring psychiatric instability, biomedical concerns, recovery environment issues, functional rehabilitation goals. Duplicate structure for additional problems.)

Problem 1: [Specific, behaviorally-anchored problem statement]

Evidence/Impact: [How the problem manifests; functional consequences and risks]

Long-Term Goal: [Patient-meaningful outcome reflecting values and preferences] (Include patient quote if provided.)

Short-Term Objectives:

• Objective 1: Patient will [specific action] [frequency] by [target date], measured by [method].
• Objective 2: Patient will [specific action] [frequency] by [target date], measured by [method].
• Objective 3: Patient will [specific action] [frequency] by [target date], measured by [method]. (Optional)

Planned Interventions:

• [Service type] – [Modality/setting], [Frequency/intensity], [Responsible clinician/role], [Patient responsibilities], [Start date], [Planned duration]
• [Referral if needed]: [Service/agency], [Purpose], [Who will initiate], [Date initiated], [Follow-up plan]

Medication (if applicable): [Medication name], [Indication], [Dose/route/frequency], [Start date], [Monitoring plan], [Adherence supports], [Safety counseling provided]

Problem 2: [Specific, behaviorally-anchored problem statement]

Evidence/Impact: [Brief description]

Long-Term Goal: [Outcome aligned with patient values]

Short-Term Objectives:

• Objective 1: Patient will [specific action] [frequency] by [target date], measured by [method].
• Objective 2: Patient will [specific action] [frequency] by [target date], measured by [method].

Planned Interventions:

• [Service type/modality/frequency/responsible role/start date/duration], [Patient responsibilities]
• [Referrals and follow-up plan]

Medication (if applicable): [Details as above]

(Add additional problems as needed using the same structure.)

Consolidated Medication List

• [Medication name] – [Dose] [Route] [Frequency]; Indication: [Indication]; Prescriber: [Name/role]; Start date: [Date]
• [Medication name] – [Dose] [Route] [Frequency]; Indication: [Indication]; Prescriber: [Name/role]; Start date: [Date]

(Include all medications for SUD, mental health, and relevant medical conditions. If no medications, state "Not applicable.")

Care Coordination

• Other providers/systems involved: [Primary care, psychiatry, pain management, probation/parole, child welfare, other] (List only those with appropriate consent documented.)
• Information sharing: [What information, with whom, purpose, consent type and dates] (Include 42 CFR Part 2 specifics when applicable.)
• Medication coordination: [Preferred pharmacy, PDMP review plan, refill monitoring]
• Crisis/after-hours contact pathway: [How to access urgent support, expected response times]

Schedule and Level of Care Summary

Current level of care and rationale: [Level of care and clinical rationale tied to assessment findings]

Weekly service schedule: [Visit types, frequency, and duration]

Step-up criteria: [Indicators: increased risk, recurrence with elevated severity, safety concerns, unmet needs]

Step-down/transition criteria: [Indicators: sustained stability, engagement, functional improvement, goal attainment]

Reassessment and Plan Review

Next Review Date: [Specific date or interval]

Reassessment Triggers: [Recurrence/return to use, overdose event, escalation of suicidal ideation, persistent inconsistent toxicology, disengagement, medication concerns, major life changes]

Data to Review: [Patient-reported outcomes, objective measures (attendance, toxicology patterns, symptom scales), collateral information with consent, functioning indicators] (Interpret toxicology within clinical context.)

Transition Planning

Anticipated next level of care: [Level of care or community supports after this episode]

Recovery supports to establish before transition: [Peer support, mutual-help groups, primary care/psychiatry follow-up, housing/employment supports, family engagement if desired]

Medication continuity plan: [Refills arranged, bridging plan, follow-up appointments, pharmacy coordination]

Patient-defined criteria for successful completion: [Patient's definition of readiness and success]

Attestations

Patient Signature/Date: [Signature and date] (If patient declined, document "Patient declined" with rationale and plan to revisit.)

Clinician Signature/Date/Credentials: [Name, credentials, signature, date]

This plan was reviewed with the patient in a language and manner the patient understands, with teach-back used to confirm understanding.