ASI Treatment Plan Template

(ASI/DENS Format)

Client Name: Willem Daniels Counselor Name: Shanna Lehman

Date / Problem Statement
06-11-2012 / Willem reports having problems within his family surrounding his alcohol consumption and feels alone; no one understands what he is going through.
06-11-2012 / Willem reports suffering negative consequences due to his alcohol consumption.
Goals
1) Find outside support for his drinking so Willem doesn’t feel alone in his progress towards sobriety.
2) Maintain sobriety by finding ways to spend more quality time with his family.
D/C Criteria / Objectives
What will the client say or do? Under what circumstances? How often will he/she say or do this?
Required / 1) Willem will attend local Alcohol Anonymous meetings at least once a week and actively participate.
Optional / 1) Keep a log of dates and times of AA meetings attended, signed by holder of meetings.
Required / 2) Record drinking patterns for one week in a self-monitor log.
Optional / 2) Go to park at least twice a week with Audrey and Sadie.
Interventions
What will the counselor/staff do to assist client? Under what circumstances? / Service Codes / Target Date / Resolution Date
1) Staff will contact local AA agency for more meeting schedule and confirm dates and times of meetings with Willem. / R / 06/18/2012 / 06/25/2012
1) Staff will check in on status of AA meetings attendance once a week. / I / 06/25/2012 / 06/25/2012
1) Staff will provide client with materials to learn more about the disease of alcoholism. / 06/25/2012 / 06/25/2012
2) Staff will look over self-monitor drinking log with client in a timely manner. / I / 06/18/2012 / 06/25/2012
2) Staff will provide client with human services directory of local agencies. / I / 06/11/2012 / 06/11/2012
2) Staff will check in on client’s sobriety progress every week. / I / 07/09/2012
Participation in Treatment Planning Process
Willem reports that he contributed to this plan, and with it.
Willem reports that he is aware of the content of this treatment plan.
Participation by Others in the Treatment Planning Process
His wife was invited to participate in the treatment planning process, but declined at this time.
Family agreed with this treatment plan.
Employer agreed with this treatment plan.

Note: All participants may not have participated in every area.

Client Signature/Date
Counselor Signature/Date

Service Codes

I=Individual G=Group F=Family C=Couples P=Psychoeducational H=Homework

R=Reading M=Media V=Videotape A=Audiotape R=Referral

Treatment Planning M.A.T.R.S.:

Utilizing the Addiction Severity Index (ASI) to Make Required Data Collection Useful