Start Here: Who Are We Helping and How?

• Who are you filling this form out for today? Options: Myself (patient), A family member / friend, A healthcare/referral professional, Employer / EAP, Court / probation officer, Other
• What's the patient's full name and date of birth?
• What's your relationship to the patient (or role if you're a referrer)? Options: Self, Parent, Spouse/Partner, Sibling, Other family, Friend, PCP/Clinician, EAP/Employer, Court/Probation, Other
• How should we contact you to discuss next steps? Options: Phone call, Text message, Email, Secure portal message, No contact — act only on instructions
• Is the patient aware of this referral and do they consent to us contacting them? Options: Yes — patient knows and consents, No — patient is unaware (safety/confidentiality reasons), Partially — some family members know, Unsure
• Where is the patient right now (this helps us assess immediate needs)? Options: At home, In a hospital/ED, At work, In public / shelter, In a vehicle, Other

This Moment Matters: What Changed Right Now?

• If nothing changes in the next 72 hours, what's the most likely worst-case outcome you fear for this person?
• What specifically triggered you to reach out today? Options: Recent overdose, Severe withdrawal symptoms, Family intervention, Employer ultimatum / EAP referral, Court mandate, Acute mental health crisis, Other
• When did the patient last use any substance (approximate date/time)? Options: Within last 24 hours, 24–72 hours ago, 3–7 days ago, More than a week ago, Unknown
• Which substances are involved right now (select all that apply)? Options: Alcohol, Heroin, Fentanyl, Prescription opioids (oxycodone, hydrocodone), Methamphetamine / amphetamines, Cocaine / crack, Benzodiazepines, Cannabis, Other / polysubstance
• How is the patient currently presenting (check all that apply)? Options: Actively withdrawing (nausea, tremors, sweating, agitation), Sedated or unresponsive, Confused or disoriented, Agitated / violent, Expressing suicidal ideation or self-harm, No acute symptoms right now, Other
• Has the patient had an overdose in the past, and was naloxone administered? Options: No history of overdose, Yes — naloxone given and revived, Yes — overdose but unknown if naloxone used, Unsure

Who's In The Room When Decisions Are Made?

• Who will have the final say about entering treatment — and what would make them say yes right now?
• Who are the people we should include in conversations (decision-makers, supports, or those we must avoid contacting)?
• Is there a legal guardian, power of attorney, or court-appointed decision-maker for healthcare? Options: Yes — legal guardian/POA (please provide name), No, Unknown
• Is the patient currently able to make and communicate informed decisions (capacity to consent)? Options: Yes — fully capable, Impaired — needs evaluation, No — currently incapable, Unsure
• Who is expected to cover costs or co-sign financial agreements if needed? Options: Patient, Family member(s), Insurance, Employer / EAP, Court/state program, Other
• Are there family dynamics or conflicts that might block treatment (custody, threats, addiction enabling, safety risks)?

The Money and the Rules: What Constraints Will Shape Care?

• What hard rules — insurance limits, court orders, or employer ultimatums — will determine where, when, or how long treatment can be?
• What type of health coverage will be used for treatment? Options: Private insurance, Medicaid / state program, Medicare, Tricare / military, VA benefits, Uninsured / self-pay, Other
• Does the insurer or referring agency require in-network placement, a specific level of care, or a prior authorization? Options: In-network required, Specific program required by court/EAP, Prior authorization required, No restrictions known, Unsure — please verify
• Is there a court order or probation requirement specifying program length or type? Options: Yes — details provided below, No, Pending / Unknown
• How concerned are you about out-of-pocket cost affecting the ability to accept recommended care? Options: Very concerned, Somewhat concerned, Slightly concerned, Not concerned
• Would you consider a short self-pay bridge or payment plan to secure immediate admission if insurance takes time? Options: Yes — willing to self-pay temporarily, Maybe — need details, No — cannot self-pay
• Do you give permission for our team to verify benefits and discuss the case with the insurer or court as needed? Options: Yes — verify benefits and coordinate, No — do not contact insurer/court, Only with written consent / POA

The Body and Mind We’re Supporting

• What untreated medical or mental health condition could undermine recovery if not addressed immediately?
• Does the patient have any diagnoses or current treatments we should know (psychiatric, chronic pain, neurological, cardiac, infectious disease)?
• Is the patient currently prescribed medications we must continue or safely manage (antidepressants, antipsychotics, seizure meds, methadone, buprenorphine)?
• Is the patient on medication-assisted treatment (MOUD/MAT)? Options: Buprenorphine (Suboxone/Subutex), Methadone, Naltrexone (Vivitrol/ oral), None, Other/Unknown
• Has the patient had seizures or other severe withdrawal complications in past detoxes? Options: Yes — had seizures, Yes — other severe complications, No, Unknown
• Is there pregnancy, breastfeeding, or potential pregnancy we must plan for? Options: Pregnant, Breastfeeding, Not pregnant / not applicable, Unknown / prefer not to say
• Does the patient have any known allergies (medication, food, environmental) that could affect care?

If This Works, What Will Be Different?

• Imagine it’s six months after discharge and this was the turning point — what specifically would be different in the patient's life?
• What are the top three goals you want treatment to achieve (select up to three)? Options: Stop using completely, Reduce use and harm, Stabilize on medication, Improve mental health, Regain custody or parenting rights, Keep or return to work, Comply with court/probation, Reconnect with family
• What measurable sign would convince you treatment is working (e.g., 30 days sober, negative urine screens, returned to work, regained custody)?
• What is the minimum length or intensity of care you believe is necessary for a meaningful chance at success? Options: Detox + 30-day residential, Detox + 60–90 day residential, Intensive outpatient / IOP, Outpatient with MAT, Unsure — need clinician recommendation
• How willing is the patient to engage in family therapy or involve family in treatment planning? Options: Very willing, Somewhat willing, Reluctant, Prefer no family involvement
• What would be a deal-breaker or non-negotiable for the patient in a treatment program (e.g., no medications, specific religious practices, female-only environment)?

Practical Realities: What Has To Be True for This To Happen?

• Which single practical obstacle is most likely to stop admission from happening quickly (transport, childcare, ID/insurance, job, housing)?
• Does the patient have valid identification and their insurance card available? Options: Yes — both available, Partial — one of them available, No — neither available, Unsure
• How will the patient get to the program if accepted (family transport, public transit, ambulance, not possible)? Options: Family / friend transport, Private vehicle, Public transit / rideshare, Ambulance / med transport, Unable to arrange
• Are there childcare, eldercare, or dependent responsibilities that require planning before admission? Options: Yes — childcare arrangements needed, Yes — eldercare needed, No dependents, Other / complex
• Can the patient be away from their home/work for the recommended length of stay (30–90 days) if clinically indicated? Options: Yes — can be away, Maybe — needs planning, No — cannot be away, Unsure
• Does the household have pets or other responsibilities that will need support while the patient is in care? Options: Yes — pets (need boarding), Yes — other responsibilities, No
• Which level of care do you think the patient is most likely to accept right now? Options: Residential inpatient, Detox only, Intensive outpatient (IOP), Outpatient counseling, Medication-assisted treatment only, Unsure — open to recommendation

Immediate Safety & Next Steps — Can We Act Now?

• If you had one instruction to give us to keep this person safe in the next 24 hours, what would it be?
• How would you rate the current level of immediate danger or medical risk? Options: Immediate life-threatening risk (call 911 now), High — urgent clinical attention needed, Moderate — needs assessment within 24 hours, Low — can schedule soon, Unsure
• Is there naloxone available at home or with a caregiver right now? Options: Yes — naloxone on site, No — do not have naloxone, Not applicable / unsure
• Do you authorize our team to contact the patient's PCP, ER, or current treating clinicians to coordinate care and share clinical recommendations? Options: Yes — contact all listed providers, Yes — contact only PCP, No — do not contact providers, Only with written consent/POA
• Do we have permission to coordinate with court, probation, or EAP as part of admission planning if required? Options: Yes — coordinate freely, No — do not coordinate, Only with specific written instructions
• What is the best time and number to reach you (or the decision-maker) to arrange admission or an urgent clinical call? Options: ASAP — any time, Morning (8am–12pm), Afternoon (12pm–5pm), Evening (5pm–9pm), Text first, then call
• Is there any other critical information we must know before taking the next step (safety concerns, triggers, recent events)?

• Current State & Urgency Confirmation
• Clinical Assessment Review & Level-of-Care Recommendation
• Solution Experience — Personalized Continuum & Recovery Milestones
• Safety, Contingency & Family Alignment

• Provide naloxone training/enrollment if clinically indicated and document completion.
• Write and circulate the clinical recommendation memo linking each care level to identified risks.
• Arrange any urgent medical consultations (addiction medicine, psychiatry) and schedule necessary diagnostics.
• Document patient/family preferences and unresolved objections for the Solution Experience meeting.
• Re-state Current State & Consequence (Precondition)
• Ensure the patient/family and clinicians clearly see how the proposed continuum directly removes the documented consequences.
• Agree on measurable recovery milestones and a preliminary timeline tied to the patient's context.
• Obtain explicit validation or a list of specific objections to be resolved before scheduling admission.
• Produce and distribute the personalized care-path document that maps each milestone to risk mitigations and owners.
• Capture and assign resolution owners for any objections raised during validation, with deadlines.
• If validated, provisionally reserve clinical slots (detox bed/residential intake) pending consent and benefits verification.
• Present Confirmed Plan Summary
• Document a concrete, signed safety and contingency plan that family and clinicians can enact immediately.
• Define and agree explicit readmission triggers and the rapid-access process.
• Clarify family/decision-maker roles and secure verbal or written commitment to specified support tasks.
• Finalize the safety and contingency plan in the patient record and distribute a copy to primary contacts.
• Enroll family in the scheduled family orientation and provide clear contact numbers for crisis access.
• Introductions & Meeting Objective
• Produce and record a crystal-clear one-sentence current-state summary agreed by all participants.
• Surface and quantify the concrete consequences of delaying treatment.
• Agree on the immediate data or consents needed before a solution experience can proceed.
• Finalize and save the one-sentence current-state in the patient file and circulate to attendees.
• Order or request prioritized clinical records/labs and assign an owner with due dates.
• Confirm who is the authorized decision-maker and request written proof if required (power of attorney/court order).
• Review of Confirmed Clinical Data
• Agree on a specific, documented level-of-care recommendation with clinical justification.
• Identify immediate clinical actions required before admission (detox orders, medication holds, consults).
• Surface any patient/family objections or constraints that would prevent recommended care.
• One-sentence Current State
• Safety Plan & Emergency Response
• Define the Future State & Success Signals (Precondition)
• Risk Stratification (Withdrawal, Overdose, Suicide)
• Medication Reconciliation & MAT Considerations
• Immediate Risks & Consequences
• Walkthrough: Personalized Continuum (Scenario-driven)
• Relapse Triggers & Contingency Pathways
• Family Roles, Boundaries & Support Tasks
• Recommended Level(s) of Care & Rationale
• Milestones, Metrics & Time-based Expectations
• Decision-makers & Constraints
• Gaps & Required Pre-work
• Validation & Commitment to Contingency Plan
• Validation & Patient/Family Preferences
• Proof Points & Evidence
• Validation Check & Commitment

• Medically supervised detoxification
• Medication-assisted treatment initiation and dosing
• Individual cognitive behavioral therapy
• Group therapy sessions
• Family therapy sessions
• Residential 24/7 inpatient treatment
• Intensive outpatient therapy sessions
• Weekly outpatient counseling sessions
• Relapse prevention workshops
• Alumni support meetings
• Psychiatric medication management for co-occurring disorders
• Crisis stabilization and overdose response
• Naloxone kit provision and training

Medically supervised detoxification

• Does the patient require medically supervised detoxification as part of the plan? Options: Yes, No, Unsure
• Which substances are driving the need for detox? Options: Alcohol, Opioids, Benzodiazepines, Stimulants (cocaine/meth), Polysubstance, Other
• What is the expected intensity of medical monitoring required during detox? Options: 24/7 nursing + physician oversight, Continuous nursing with daily physician rounds, Intermittent nursing with on-call physician, Medical observation only as needed
• Based on clinical history, what is the anticipated detox duration? Options: 48-72 hours, 3-7 days, 7-14 days, More than 14 days, Unknown / needs assessment
• Is there a prior history of complicated withdrawal (seizures, delirium tremens, severe autonomic instability)? Options: Yes, No, Unknown
• Please list any medical comorbidities, mobility issues, or special needs that would affect detox placement or monitoring.

Medication-assisted treatment initiation and dosing

• Should MAT (e.g., buprenorphine, methadone, naltrexone, acamprosate) be started during this episode of care? Options: Yes - initiate now, Yes - plan to initiate after detox, No, Unsure
• Which MAT agents are being considered or preferred based on clinical history? Options: Buprenorphine/Suboxone, Methadone, Naltrexone (oral/injectable), Acamprosate, None / other, Unsure
• Is there prior exposure to MAT or previous adverse reactions to these medications? Options: No prior MAT, Prior MAT without issues, Prior MAT with adverse reaction - specify, Unknown
• What level of monitoring and follow-up for dosing is required (e.g., daily dosing, weekly visits, observed dosing)? Options: Daily observed dosing, Multiple weekly visits, Weekly or biweekly follow-up, Monthly medication management, Remote/telehealth follow-up
• Are there prescribing constraints to consider (pregnancy, hepatic/renal impairment, opioid receptor agonist policies, regulatory requirements)? Options: Yes - list in next field, No, Unknown
• Provide any details on PDMP checks, pharmacy restrictions, or other regulatory/consent details relevant to MAT initiation.

Individual cognitive behavioral therapy

• Should individual CBT be included in the care plan? Options: Yes - weekly, Yes - multiple times weekly, No, Unsure
• What are the primary therapeutic goals for individual CBT (e.g., craving management, trauma processing, coping skills, relapse prevention)? Options: Craving management, Trauma/IPV treatment, Co-occurring depression/anxiety, Behavioral activation, Relapse prevention skills, Other
• What frequency and session length are clinically appropriate? Options: 30 minutes weekly, 45-60 minutes weekly, 2-3x weekly, Short-term intensive (multiple sessions per week)
• Are there language, cultural, or accessibility needs for the individual therapist assignment? Options: Yes - specify in next field, No
• Does the patient have co-occurring cognitive limitations or neurodevelopmental needs that affect therapy modality? Options: Yes, No, Unknown
• Any notes on patient readiness, prior therapy history, or contraindications for CBT (e.g., active psychosis)?

Group therapy sessions

• Should group therapy be included in the care plan? Options: Yes - daily groups, Yes - several times weekly, Yes - weekly, No, Unsure
• Which group formats are preferred or clinically recommended? Options: Process groups, Psychoeducational groups, Skills-based (DBT/CBT) groups, 12-step style peer groups, Gender-specific groups, Other
• What is the ideal group size and composition (e.g., small therapeutic group 6-8, large psychoeducation 15+)? Options: Small (6-8), Medium (9-15), Large (15+), Not applicable / flexible
• Are virtual/tele-group options required for access or continuity? Options: Yes - fully virtual, Hybrid (in-person + virtual), No - in-person only
• Are there content priorities for groups (e.g., trauma-informed care, craving coping skills, employment readiness)?
• List any safety or membership restrictions (e.g., gender identity, age group, court-mandated participants) that affect group placement.

Family therapy sessions

• Should family therapy be part of the treatment scope? Options: Yes - mandated/required, Yes - recommended, No, Unsure
• Who are the expected family participants (parents, spouses, adult children, guardians)? Options: Parent(s), Spouse/Partner, Adult child, Legal guardian, Other
• What are the primary goals for family sessions (education, boundary setting, communication skills, reunification)? Options: Psychoeducation on SUD, Boundary & relapse planning, Communication/repair, Supporter coping skills, Legal/court coordination, Other
• What frequency and duration for family therapy is appropriate? Options: Weekly, Biweekly, Monthly, As-needed/episodic
• Are there confidentiality or consent requirements to document before family participation? Options: Yes - documented consent needed, No, Unknown
• Please list any family dynamics, legal constraints, or safety concerns that should guide family therapy planning.

Residential 24/7 inpatient treatment

• Is 24/7 residential inpatient placement being considered or required? Options: Yes - immediate placement, Yes - after detox, No, Unsure
• What length of stay range is clinically recommended (select best estimate)? Options: 30 days, 45-60 days, 90 days, 3-6+ months, Flexible/needs assessment
• What level of on-site medical and behavioral supports are required (e.g., on-call MD, in-house RN, psychiatric availability)? Options: On-site MD + RN 24/7, RN with on-call MD, Therapist-led with medical consults, Low medical support
• Are specific accommodations required (private room, wheelchair accessibility, gender-specific unit)? Options: Private room needed, Wheelchair accessible, Gender-specific placement, None, Other
• Are there insurance, legal, or court-mandated constraints that affect residential admission and length? Please describe.

Intensive outpatient therapy sessions

• Should intensive outpatient programming (IOP) be included in the continuum? Options: Yes - full IOP (9+ hours/week), Yes - partial IOP (6-9 hours/week), No, Unsure
• Which days/hours are feasible for the patient to attend IOP (work/school considerations)? Options: Weekdays daytime, Evenings, Weekends, Flexible/hybrid
• Does the patient require on-site medication management or can they receive meds externally while in IOP? Options: On-site medication management, External pharmacy/clinic for meds, No medication required
• Is transportation or childcare a barrier to attending IOP that we need to plan for? Options: Yes - transportation, Yes - childcare, Both, No
• What clinical severity or risk criteria should trigger step-up from IOP to residential care?
• Any cultural, language, or accessibility needs that should be accommodated in IOP groups and sessions?

Weekly outpatient counseling sessions

• Should weekly outpatient counseling be part of the discharge/aftercare plan? Options: Yes - standard weekly, Yes - biweekly, No, Unsure
• Preferred modality for outpatient sessions? Options: In-person only, Telehealth only, Hybrid (in-person + telehealth)
• What measurable progress indicators should outpatient counseling track (e.g., drug screens, attendance, validated scales)? Options: Urine drug screens, Attendance/adherence, Validated symptom scales (PHQ-9,GAD-7), Self-report craving scales, Other
• Is case management (housing, employment, benefits) required as part of outpatient services? Options: Yes - intensive, Yes - light touch, No
• Are there payer or authorization limits that affect the frequency or duration of outpatient counseling? Options: Yes - please specify, No, Unknown
• Please provide any notes on the patient's schedule constraints, commute time, or technology access that affect outpatient delivery.

Relapse prevention workshops

• Should structured relapse prevention workshops be included in the plan? Options: Yes - weekly workshops, Yes - monthly workshops, No, Unsure
• Which curriculum topics are highest priority (e.g., trigger identification, coping skills, medication adherence)? Options: Trigger identification, Coping & skills training, Stress management, Medication adherence, Sober support planning, Other
• What are appropriate measurable outcomes for these workshops (e.g., skill competency checks, reduction in cravings, attendance rates)?
• Should workshops include practicum/role-play and homework with clinician review? Options: Yes - include practicum, No - didactic only, Hybrid
• Are booster or refresher modules required post-discharge and at what intervals? Options: 30-day booster, 90-day booster, 6-month booster, No booster
• Any language, literacy, or cultural adaptations needed for workshop materials?

Alumni support meetings

• Should alumni support (peer groups, mentorship) be part of ongoing care? Options: Yes - weekly meetings, Yes - monthly meetings, Yes - peer mentor assigned, No
• What format do alumni meetings need to provide (in-person, virtual, hybrid)? Options: In-person, Virtual, Hybrid
• Who will own alumni outreach and engagement (clinical team, alumni coordinator, volunteer peers)? Options: Clinical team, Dedicated alumni coordinator, Volunteer peer leaders, Other
• What engagement metrics should be tracked for alumni (attendance, relapse/readmission rates, peer mentor activity)? Options: Attendance, Readmission rates, Mentor-mentee matches, Satisfaction scores, Other
• Do alumni participants require boundaries or eligibility rules (e.g., must have completed X days of treatment)? Options: Yes - specify in next field, No
• Please note any special needs for alumni programming (transportation, childcare, stigma concerns).

Psychiatric medication management for co-occurring disorders

• Is psychiatric medication management required for diagnosed or suspected co-occurring mental health conditions? Options: Yes - active management needed, Yes - evaluation only, No, Unsure

• Statement of Work (SOW)
• Insurance Benefits Verification & Estimate
• Financial Responsibility & Payment Agreement
• Consent to Treatment (Informed Consent)
• Medication-Assisted Treatment (MAT) Consent
• Consent for Medical Detoxification & Emergency Care
• HIPAA Authorization & Privacy Notice Acknowledgment
• Release of Information & Family Communication Agreement
• Legal Mandates & Court Order Acknowledgment
• Readmission, Discharge & Aftercare Policy Agreement
• Refund, Cancellation & Insurance Denial Policy
• Facility Rules, Code of Conduct & Safety Agreement
• Electronic Payment Authorization & Billing Consent
• Guardianship / Power of Attorney & Decision-Maker Authorization
• Telehealth & Remote Services Consent

• Quarterly Clinical Outcomes Review
• Aftercare Transition & Discharge Planning
• Rapid Response & Readmission Case Conference
• Family & Caregiver Support and Education Session
• Alumni Engagement & Community Reintegration Planning

• Establish clear caregiver roles and emergency contacts for the shared channel.
• Enroll patient in alumni/onboarding group and create shared communication channel for first 90 days.
• Incident Triage Summary
• Decide an immediate, time-bound disposition to safeguard patient safety and continuity of care.
• Mobilize operational resources (bed, transport, authorization) within defined timelines.
• Ensure clear communication to patient/family and record actions for legal/clinical traceability.
• Initiate admission or crisis stabilization within the agreed timeframe and confirm transport arrangements.
• Alert payer and secure any emergency authorizations required for immediate care.
• Assign a case manager to follow the patient through the first 72 hours and update the shared channel.
• Progress Brief
• Ensure family understands the patient's recovery status and concrete steps to take if risk escalates.
• Equip caregivers with communication tools to support recovery without enabling harmful behaviors.
• Introductions & Objectives
• Enroll family members in scheduled education workshops and provide written relapse response plan.
• Add designated caregivers to the shared communication channel with permission and role definitions.
• Provide a one-page resource sheet (crisis hotline, transport options, local support groups).
• Engagement Metrics Review
• Create a sustainable community support plan that reduces isolation and supports relapse prevention.
• Assign a peer mentor and ensure clear expectations and initial contact within 72 hours.
• Set measurable long-term follow-up schedule and owners for outcome tracking.
• Confirm peer mentor match and schedule first 1:1 contact within 72 hours.
• Register patient for two relevant alumni events/workshops within the next 30 days.
• Document 3/6/12-month outcome checkpoints in shared tracker and assign outreach owner.
• Validate whether the patient is meeting established clinical success signals.
• Decide on any required changes to level of care, medications, or therapeutic focus.
• Assign clear owners and measurable follow-up targets with timelines.
• Update individualized care plan with agreed adjustments and measurable targets.
• Schedule next outcomes checkpoint and assign data owner to populate progress dashboard.
• Notify patient/family and outpatient team of changes and document consent where needed.
• Readiness Assessment
• Produce a signed, time-bound aftercare plan with appointments and medication continuity confirmed.
• Eliminate administrative barriers (insurance, transport, consent) that could delay transition.
• Ensure the patient and family understand the relapse contingency and readmission process.
• Book outpatient and MAT appointments within 7 days post-discharge and share calendar invites.
• Complete prior authorization and send prescriptions to designated pharmacy.
• Peer Mentor Assignment & Expectations
• Relapse Indicators & Immediate Steps
• Medication & MAT Continuity
• Current State Snapshot
• Medical & Legal Constraints
• Communication & Boundary Setting
• Success Signals Review
• Disposition Options & Consequences
• Outpatient & Community Appointments
• Community Resource Coordination
• Consequence & Risk Assessment
• Logistics & Barriers
• Practical Supports & Resources
• Alumni Programming Calendar
• Insurance, Consent & Documentation
• Communication & Documentation
• Care Plan Adjustments
• Relapse Contingency Plan
• Q&A and Role Assignments
• Long-term Outcome Tracking
• Family & Social Support Alignment
• Ownership, Timing & Metrics