DRUG AND ALCOHOL ABUSE PREVENTION AND TREATMENT PROGRAMS

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NAVMC 2931 MARINE CORPS DRUG AND ALCOHOL ABUSE PREVENTION AND TREATMENT PROGRAMS II FOREWARD 1. PURPOSE This publication, NAVMC 2931, Substance Abuse Program, is to be utilized by commanders and substance abuse program personnel to meet the drug and alcohol prevention and treatment requirements of MCO P1700.24B. 2.

SCOPE NAVMC 2931 does not amend nor change existing directives, orders or policy of this or higher authority, if conflicts arise, published directives and/or orders take precedence. 3. SUPERSESSION None 4.

ADDITIONAL COPIES For additional copies refer to MCO P5600.31. 5. CERTIFICATION Reviewed and approved this date.

DISTRIBUTION: PCN 10010362100 Copy to: III INTRODUCTION cAlcohol abuse and the distribution, possession or use of illegal drugs is contrary to the effective performance of Marines and to the Marine Corps 9 Mission, and will not be tolerated in the Marine Corps. d MCO P1700.24B The Marine Corps objective is to improve the capability of commanders and their Marines to prevent drug/alcohol abuse related problems that detract from unit performance and readiness. Every attempt will be made to prevent drug/alcohol abuse through proactive and reactive measures. The most effective and long-term program is one that promotes an attitude of overall responsibility on the part of the individual Marine.

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NAVMC sets forth procedures for drug and alcohol prevention and treatment programs. Essential steps in achieving the objectives of this program are to: Change the attitudes of Marines toward alcohol use. Ensure every Marine understands the important role they have in the defense of our Nation, and the adverse impact excessive drinking/illegal drug use has on themselves, fellow Marines, our Corps, and their families. This effort requires a total leadership commitment of all officers, staff noncommissioned officers, and noncommissioned officers. Leaders must set the example and ensure that all Marines are aware of the Marine Corps commitment to prevent drug and alcohol abuse. In short, Marine Corps leaders must reinforce the policy that drug or alcohol abuse is not tolerated and that Marines who abuse these substances will be held accountable for their actions. IV TABLE OF CONTENTS Page INTRODUCTION&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& iii CHAPTER I DRUG AND ALCOHOL ABUSE PREVENTION PROGRAM&&& 1-1 II SUBSTANCE ABUSE TREATMENT PROGRAM&&&&&&&&&&& 2-1 III ADMINISTRATIVE FORMS AND APPLICATIONS&&&&&&& 3-1 1-1 CHAPTER ONE Page DRUG AND ALCOHOL ABUSE PREVENTION&&&&&&&&&&&&&& 1-2 1-2 DRUG AND ALCOHOL ABUSE PREVENTION 1. Drug and alcohol prevention education alone is not the answer to preventing abuse. However, if properly conducted, prevention education can provide potential/present abusers with information to clarify personal values, improve problem solving and decision making skills, and understand alternative lifestyle choices. Tools such as these will help the individual Marine make a more informed decision concerning drug/alcohol abuse. 2. MCO P1700.24B requires Officers and SNCOs to receive annual supervisor training in drug and alcohol abuse prevention. Civilian employees in supervisory positions of Marines receive supervisor training upon assumption of supervisory duties and every 2 years thereafter. The learning objectives below shall be used to meet this requirement. a. To state the Marine Corps 9 policy on drug/alcohol abuse and dependence as contained in this Manual. b. To describe the difference between responsible drinking and alcohol abuse. c. To describe the importance of recreation activities as alternatives to drug/alcohol abuse. d. To describe the early warning signs and progressive nature of drug and alcohol abuse. e. To describe the supervisor 9s role in setting a positive example, preventing alcohol abuse, the identification and referral of abusers, and the alcohol abuse/dependency recovery process. f. To describe Marine Corps policy on illegal drug use and urinalysis testing as reflected in this manual. 3. In addition to the Officer and SNCO annual training objectives (a) through (f), Noncommissioned Officers are required to receive drug and alcohol abuse prevention training through a CMC (MR) approved course provided by the Installation Substance Abuse Counseling Center (SACC). NCOs will provide this prevention training to their subordinates annually. This NCO training course is a one-time requirement. However, it does not preclude NCOs from participating in additional unit prevention training. The course learning objectives are: 1-3 a. To describe the impact drug and alcohol abuse has on mission readiness. b. To describe the role of the small unit leader in preventing drug and alcohol abuse. c. To describe how alcohol is absorbed, processed, and eliminated from the body. d. To define Blood Alcohol Level (BAL). e. To identify factors that influence BAL. f. To explain alcohol effects at various BALs. 2-1 CHAPTER TWO Page SUBSTANCE ABUSE TREATMENT PROGRAM&&&&&&&&&&&&&&&&&&&&&&& 2-2 PATIENT PLACEMENT CRITERIA GRID&&&&&&&&&&&&&&&&&&&&& 2-4 EARLY INTERVENTION&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2-5 OUTPATIENT PROGRAM&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 2-6 INTENSIVE OUTPATIENT PROGRAM&&&&&&&&&&&&&&&&&&&&&& 2-7 2-2 SUBSTANCE ABUSE TREATMENT PROGRAM 1. Per SECNAVINST 5300.28C and MCO P1700.24B, the Marine Corps is required to identify, counsel, or rehabilitate Marines identified as drug/alcohol abusers or drug/alcohol dependent. 2. MCO P1700.24B requires Substance Abuse Intervention and Treatment to be conducted at base, station, or depot Substance Abuse Counseling Centers by qualified personnel (e.g., substance abuse counselors, physicians, psychologists, et al., with requisite skills and training). This order additionally requires that treatment be provided, under the supervision of a Licensed Independent Practitioner (LIP) (physician or clinical psychologist). 3. Under no circumstances will a substance abuse treatment program established under the auspices of this Manual be degrading or punitive in nature. SACC outpatient services will be designed to address the individual 9s needs and to achieve permanent changes in drug/alcohol use behaviors. Inpatient services will be provided at military hospitals. 4. To meet the requirements of SECNAVINST 5300.28C and MCO P1700.24B, SACCs will provide drug and alcohol services to include screening, early intervention, comprehensive biopsychosocial assessments, and individualized treatment (except for drug dependence) using a continuum of care model and the Patient Placement Criteria (admission and discharge) below. a. Placement will be based on the seven continuum of care assessment dimensions, not the drug and alcohol diagnosis. A Marine will be assessed using the placement criteria contained below. The assessment information will be used by the Case Manager and the Interdisciplinary Team to recommend the Marine 9s placement to the Licensed Independent Practitioner. This will always be the least intensive portal of entry that will accomplish the treatment objectives while providing safety and security for the patient. A Marine may enter the continuum of care at any portal. b. The seven dimensions are : (1) Acute Intoxication/Potential for Withdrawal . Is there a risk of withdrawal symptoms or seizures, based on the patient 9s previous history, amount, frequency, and recency of discontinuation or significant reduction of alcohol or other drug use? Are there current signs of withdrawal? 2-3 (2) Biomedical Complications . Are there current physical illnesses, other than withdrawal, that need to be addressed or that may complicate treatment? (3) Emotional/Behavioral Complications . Are there current psychiatric illnesses or psychological, behavioral or emotional problems that need to be addressed? Do any emotional/behavioral problems appear to be an expected part of additional illness or do they appear to be autonomous? Even if connected to the addiction, are they severe enough to warrant specific mental health treatment? (4) Program Acceptance/Resistance . Is the patient actively objecting to treatment? Does the patient feel coerced into treatment? How ready is the patient to change? If willing to accept treatment, how strongly does the patient disagree with others 9 perception that he or she has an addiction problem? Does the patient appear to be compliant or does he or she appear to be internally distressed in a self- motivated way? (5) Relapse Potential . Is the patient in immediate danger of continued severe distress and drinking/drug-taking behavior? Does the patient have any recognition of, understanding of, or skills with which to cope with his or her addiction problems in order to prevent relapse or continued use? What severity of problems and further distress will potentially continue or reappear if the patient is not successfully engaged in treatment at this time? How aware is the patient of relapse triggers, ways to cope with cravings to use, and skills to control impulses to use? (6) Recovery Environment . Are there any family members, significant others, living situations, or school/working situations that pose a threat to treatment engagement and success? Does the patient have supportive friendships, financial resources, or educational/vocational resources that can increase the likelihood of successful treatment? Are there legal, vocational, social service agency, or criminal justice mandates that may enhance the patient 9s motivation for engagement in treatment? (7) Operational Commitment . Does the command operational tempo allow for participation in the recommended treatment program? If not, has the command taken action to schedule the Marine for outpatient services. For drug/alcohol dependent Marines, has action been taken for admission into a residential/inpatient program? PATIENT PLACEMENT CRITERIA GRID DIMENSIONS EARLY INTERVENTION OUTPATIENT INTENSIVE OUTPATIENT RESIDENTIAL MEDICALLY MANAGED WITHDRAWAL No significant risk No significant risk No significant risk No significant risk Significant withdrawal risk BIOMEDICAL If biomedical problems, non- interfering If biomedical problems, non- interfering If biomedical problems, non- interfering If biomedical problems, non- interfering Requires 24 hrs medical/nursing care EMOTIONAL/ BEHAVIORAL If emotional/ behavior problems, non-interfering If emotional/ behavior problems, requires minimal structure and support If emotional/ behavior problems, requires minimal structure and support Alcohol Dependent emotional/ behavioral problems interfere, require Milieu setting Serve problems, require 24 hrs psychiatric care PROGRAM/ TREATMENT ACCEPTANCE Willing to participate Motivated and/or willing to cooperate Acknowledges problem. Requires monitoring/ motivation Acknowledges problem. requires Milieu setting. N/A RELAPSE POTENTIAL Able to achieve program goals in an educational setting. Able to maintain abstinence and achieve treatment goals with minimal support and structure. Able to maintain abstinence and achieve treatment goals with close monitoring and support. High likelihood of use without close monitoring in a Milieu setting. N/A RECOVERY ENVIRONMENT Supportive environment and/or skills to cope. Supportive environment and/or skills to cope. Coping skills and/or recovery environment requires additional support. Unable to cope with recovery environment, needs Milieu setting. N/A OPERATIONAL COMMITMENTS N/A Command willing to commit to treatment requirements. Command willing to commit to treatment requirements. Schedule does not allow participation in another treatment program at this time. N/A 2-4 EARLY INTERVENTION DIMENSIONS ADMISSION CRITERIA DISCHARGE CRITERIA KEY OBJECTIVES WITHDRAWAL 1. W.A.S. <10 1. W.A.S. >10, evaluate for detoxification. 1. Monitor withdrawal signs and symptoms through W.A.S. BIOMEDICAL 1. If problems, non- interfering 1. Change in biomedical condition interferes with program. 1. Monitor for change in biomedical condition. EMOTIONAL BEHAVIORAL 1. Able to comprehend and participate in program. 2. No risk of harm to self and/or others. 3. If problems, non- interfering. 1. Completion of program requirements. 2. Risk of harm to self and/or others, refer to MHU. 3. Demonstrates inability to maintain recovery program without more intensive intervention. 4. Consistently fails to meet program objectives, no further progress likely. 1. Monitor for change in emotion/behavioral problems. 2. Statements and behaviors reflect understanding of responsible use. 3. Monitor for risk of harm to self and/or others. SERVICE ACCEPTANCE/ RESISTANCE 1. Willing to participate. 1. Acknowledgment of negative consequences of use. 2. No longer willing to participate, despite program efforts, and is recommended for further assessment. 1. Statements/behaviors reflect acknowledgment of personal responsibility. 2. Client 9s self- assessment demonstrates acknowledgment of personal responsibility. CONTINUED PROBLEM POTENTIAL 1. Needs to acquire the specific skills needed to change current pattern of use. 1. Development of alternative coping skills to prevent further alcohol related incidents. 1. Client creates relapse prevention plan using course curriculum. LIVING ENVIRONMENT 1. Supportive environment and/or skills to cope. 1. Development of alternative coping skills to prevent further alcohol related incidents. 2. Development of alternative sources of support. 1. Client identifies environmental stressors and triggers. 2. Client identifies strategies to cope with environmental stressors and triggers. 2-5 OUTPATIENT PROGRAM DIMENSION ADMISSION CRITERIA DISCHARGE CRITERIA KEY OBJECTIVES WITHDRAWAL 1. W.A.S. <10 1. W.A.S. >10, evaluate for detoxification. 1. Monitor withdrawal signs and symptoms through W.A.S. BIOMEDICAL 1. If biomedical problems, non- interfering. 1. Change in biomedical condition interfers with treatment. 1. Monitor for change in biomedical condition. EMOTIONAL/ BEHAVIORAL 1. Able to comprehend and participate in the program. 2. No risk of harm to self and others. 3. Able to cope with emotional/behavioral stressors but requires monitoring. 1. Emotional/behavioral stressors have diminished in acuteness, no longer requires monitoring. 2. Risk of harm to self and/or others, refer to MHU. 3. Completion of individual treatment goals. 4. Demonstrates inability to cope with stressors without more intensive care. 1. Monitor for changes in emotional/behavioral problems. 2. Monitor for risk of harm to self and/or others. 3. Utilize self/peer/counselor assessments to evaluate ability to cope with emotional/behavioral problems. TREATMENT ACCEPTANCE 1. Motivated and willing to participate. 1. Client recognizes extent of alcohol problems. 2. Client understands consequences of continuing pattern of abuse. 3. Client fails to recognize extent of problems. No further progress likely. 1. Client 9s self-assessment demonstrates recognition of alcohol problem and impact on functioning. 2. Client 9s statements/behaviors indicate recognition of problem. 3. Assess specific motivation underlying treatment acceptance. 4. Completion of continuing care plan reflects commitment to ongoing recovery program. RELAPSE POTENTIAL 1. Able to maintain abstinence with minimal support. 1. Client experiencing exacerbation of alcohol seeking behaviors or cravings necessitating more intensive care. 2. Applying essential knowledge and skills to sustain healthy relationship with alcohol. 1. Statements/behaviors reflect absence of alcohol cravings. 2. Assignments reflect recognition and application of coping skills. 3. Individual/group processing stressors indicate ability to apply alternative strategies. RECOVERY ENVIRONMENT 1. Sufficient skills to cope with recovery environment. 1. Sufficient support for recovery to allow transfer to less intensive care. 2. Client unable to cope with recovery environment without more intensive care. 1. Consult with command/family to create more supportive environment. 2. Counselor and client identify stressors and begin problem solving. 3. Client demonstrates awareness and commitment to alternative support systems. 2-6 INTENSIVE OUTPATIENT PROGRAM DIMENSION ADMISSION CRITERIA DISCHARGE CRITERIA KEY OBJECTIVES WITHDRAWAL 1. W.A.S. <10. 1. W.A.S. >10, evaluate for detoxification. 1. Monitor withdrawal signs and symptoms through W.A.S. BIOMEDICAL 1. If biomedical, non- interfering. 1. Change in biomedical condition interfers with treatment. 1. Monitor for change in biomedical condition. EMOTIONAL/ BEHAVIORAL 1. Able to comprehend and participate. 2. No risk to self or others. 3. Emotional/behavioral conditions are stable, being concurrently addressed, or have been assessed as non- interfering. 1. Emotional/behavioral stressors have diminished in acuteness, close monitoring no longer required. 2. Risk of harm refer to MHU. 3. Demonstrates inability to cope with stressors without clinically directed interventions. 4. No further progress likely. 1. Monitor for changes in emotional/behavioral problems. 2. Monitor for risk of harm to self and/or others. 3. Utilize self/peer/counselor assessments to evaluate ability to cope with emotional/behavioral problems. TREATMENT ACCEPTANCE 1. Amenable and willing to participate. 2. Client requires motivational strategies to sustain personal responsibility in developing a recovery program. 1. Client understands extent of problems with alcohol and the consequences of continued patterns of use. 2. Client accepts need for continued assistance in recovery. 3. Fails to recognize severity of problem, no further progress likely. 1. Client will begin to evidence awareness as to the extent of the problem and begin to develop self motivation to continue recovery efforts. 2. Client will complete a plan for recovery that reflects reliance on a primary recovery program. RELAPSE POTENTIAL 1. Able to maintain abstinence with close monitoring and support. 1. Client is applying knowledge and skills to sustain abstinence/recovery. 2. Client recognizes and understands the relapse process and has developed knowledge and skills to interrupt and manage these processes. 3. Client is experiencing an exacerbation of alcohol seeking behaviors and cravings necessitating more intensive care. 1. Client 9s statements/behaviors reflect absence of alcohol cravings. 2. Assignments indicate a recognition and application of coping skills for dealing with cravings and relapse. 3. Client demonstrates ability to cope with internal/external stressors by applying alternative strategies. RECOVERY ENVIRONMENT 1. Sufficient skills to cope with recovery environment with structure and support. 1. Sufficient support for recovery exists. 2. Insufficient support and/or skills to cope, require a more intensive level of treatment. 1. Consultation with command/family indicate a supportive environment. 2. Counselor and client have identified coping strategies to apply toward environmental stressors. 3. Client has begun reintegration into various systems. 2-7 3-1 CHAPTER THREE ADMINISTRATIVE FORMS Page DRUG/ALCOHOL ABUSE TREATMENT ASSIGNMENT LETTER&&&&&&&&&&&& 3-2 SUBSTANCE ABUSE CLINICAL PACKAGE&&&&&&&&&&&&&&&&&&&&&&&&&& 3-4 CONSENT TO OBTAIN INFORMATION&&&&&&&&&&&&&&&&&&&&&&&&& 3-5 COUNSELOR 9S ASSESSMENT NOTE&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-6 COUNSELOR 9S ASSESSMENT AND RECOMMENDATION&&&&&&&&&&&&& 3-10 DISPOSITION OF REFERRED PROBLEM&&&&&&&&&&&&&&&&&&&&&&& 3-12 FAMILY AND CULTURAL HISTORY&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-13 EDUCATION AND WORK HISTORY&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-15 MILITARY HISTORY&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-16 SOCIALIZATION, SELF CONCEPT AND COMMUNICATION HISTORY&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-17 FINANCIAL HISTORY&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-18 SPIRITUAL AND RELIGION HISTORY&&&&&&&&&&&&&&&&&&&&&&&& 3-19 LEGAL HISTORY&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-20 EMOTIONAL AND BEHAVIORAL HISTORY&&&&&&&&&&&&&&&&&&&&&& 3-21 INDIVIDUAL TREATMENT PLAN&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-23 INFORMATION RELEASE AUTHORIZATION&&&&&&&&&&&&&&&&&&&&& 3-25 SIGNIFICANT OTHER ASSESSMENT FORM DRUG/ALCOHOL&&&&&&&& 3-26 FOLLOW-UP EVALUATION&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-29 PRIVACY ACT STATEMENT&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-33 CONFIDENTIALITY OF ALCOHOL/DRUG ABUSE PATIENT RECORDS STATEMENT&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-35 ALCOHOL ABUSE PREVENTION SPECIALIST&&&&&&&&&&&&&&&&&&&&&&& 3-36 ALCOHOL ABUSE PREVENTION SPECIALIST SCREENING FORM&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-37 INSTRUCTIONS FOR THE INTERVIEWER&&&&&&&&&&&&&&&&&&&&&& 3-39 SUBSTANCE ABUSE COUNSELOR APPLICATION&&&&&&&&&&&&&&&&&&&&& 3-44 COMMAND SCREENING TOOL FOR NDACS CANDIDATES&&&&&&&&&&& 3-46 NDACS INTERVIEW INSTRUMENT&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-48 URINALYSIS COLLECTION MATERIAL&&&&&&&&&&&&&&&&&&&&&&&&&&&& 3-53 3-2 ADMINISTRATIVE FORMS AND APPLICATIONS LETTERHEAD 5300 SACO Date From: Commanding Officer To: Rank/Name/SSN/MOS of Member being assigned Subj: ASSIGNMENT TO DRUG/ALCOHOL ABUSE TREATMENT Ref: (a) MCO P1700.24_ (b) MCO P1900.16_ 1. In accordance with reference (a), you are assigned to Outpatient/Intensive Outpatient/Residential Treatment, where you will receive treatment for alcohol/drug abuse. You will report to the Substance Abuse Counseling Center, Bldg _____ at __ on __ . ( Time) (Date) 2. The following is expected of the participants in the treatment program: a. All sessions will be attended. b. Completion of individual rehabilitation plan. c. Active participation in the class sessions. d. No consumption of alcohol or any other drug during treatment. e. Attendance at Twelve Step groups (if assigned). f. Completion of homework assignments. g. Follow additional rules/guidelines of the SACC. Figure 5-1.--Format of a Letter of Assignment to Outpatient Services. 3-3 Subj: ASSIGNMENT TO DRUG/ALCOHOL ABUSE TREATMENT 3. In accordance with paragraph 6209 of reference (b), a Marine referred to a program of rehabilitation for personal alcohol abuse may be separated for failure through the inability or refusal to participate in, cooperate in, or successfully complete such a program. C O 9s Signature - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - SACO Date FIRST ENDORSEMENT From: Rank/Name/SSN/MOS of Member being assigned To: Commanding Officer 1. I understand and acknowledge receipt of this assignment letter and the consequences of refusing treatment or not successfully completing the program. Signature of Member Being Assigned Copy to: SACC Unit case file Figure 5-1.--Format of a Letter of Assignment to Outpatient Services. 3-4 SUBSTANCE ABUSE CLINICAL PACKAGE AUDIO/VIDEO ACKNOWLEDGMENT FORM On certain occasions, interviews and treatment sessions may be audio/video taped, and/or observed. The purpose of these procedures is to provide for high quality professional services and for use in training Navy/Marine Corps Drug and Alcohol Counselors. I, _______________________________, acknowledge the production of audio/video tape recordings, closed circuit television viewing, or other forms of observation at (provide location) for the above purposes. I understand that all information so obtained will be handled in confidence to the extent allowed by law. Per the Privacy Act Statement for Marine Corps Drug and Alcohol Counseling Records, I understand this information will not be released to unauthorized agencies or individuals without my express, written consent. Client Name:__________________Client SSN:__________________ Client Signature:_________________________ Date:___________ Counselor Signature:______________________ Date:___________ 1 OF 1 3-5 CONSENT TO OBTAIN INFORMATION The purpose or need for this information is to assist the staff in my rehabilitation efforts. I understand I may revoke this consent to obtain information at any time and that upon fulfillment of the stated purpose(s); this consent will automatically expire without my express revocation. Unless sooner revoked or fulfilled, this consent will expire one year from the date signed. Information provided by other professionals will become part of my case file and will be subject to the rules on confidentiality contained in MCO P1700.24_. I realize this communication will reveal my presence in treatment to the person contacted. Communication between_____________________and____________________ Internal Program Person or Agency ADDRESS ADDRESS _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ City, state and zip code City, state and zip code Attn:__________________________ Attn:__________________________ as specified and agreed to as follows: Obtain information for the following purpose(s): ______________________________________________________________________ ____________________________________________________________ Information to be obtained related to my: ____ chemical usage ____ medical history ____ social history/background ____ education ____ other (specify):____________________________________________ Methods for obtaining authorized information are: ____ concerned person questionnaire ____ written ____ telephone ____ other (specify):____________________________________________ NOTE: This information being requested from you is protected under confidentiality requirement by Federal Law. Federal regulations prohibit disclosure of this information without the express written consent of the client to whom it pertains, or as otherwise permitted by such regulations. A general medical authorization for the release of medical or other information is not sufficient for this purpose. Client Name:_____________________ Client SSN:___________________ Client Signature:_____________________________ Date:____________ Counselor Signature:___________________________ Date:___________ 3-5 1 of 1 3-6 COUNSELORS' ASSESSMENT NOTE 1. Identifying information & description of client. - Age: ___________________________________________________ - Marital Status: ________________________________________ - Race: __________________________________________________ - Rank: __________________________________________________ - Branch of Service: _____________________________________ - Length of Service: _____________________________________ - Duty Station: __________________________________________ 2. Circumstance prompting admission & motivation for treatment: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Current living arrangements & relationships: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. Chemical dependency history: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5. Pertinent past history (including psychiatric & suicidal): ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 1 of 4 6. Assessments: 3-7 NOTE : It is permissible to state "no identified areas of concern" in individual sections - Family and Cultural ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ - Education and Work ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ - Military ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ - Socialization, Self-Concept and Communications ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ - Recreational and Leisure ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2 of 4 3-8 - Financial ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ - Spirituality and Religion ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ - Legal ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ - Emotional and Behavioral ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ - Current Needs and Concerns ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ - Current Suicidal Ideation ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3 OF 4 3-9 7. Summary of Patient 9s Strengths: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 8. List problems to be addressed at intake by counselor on Treatment Plan: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 9. List possible concerns to be discussed during treatment committee meetings: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Additional comments: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Client Name:__________________ Client SSN:_________________ Counselor Signature:______________________ Date:___________ 4 of 4 3-10 COUNSELOR ASSESSMENT AND RECOMMENDATION Diagnosis/Diagnostic Impression: ____ Alcohol Abuse ___ Drug Abuse ____ Alcohol Dependency ___ Drug Dependency ____ None Other __________________ Counselor Diagnostic Impression and Assessment: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Recommendations : _____ Return to duty. No further counseling or assistance indicated at this time. _____ Early Intervention ____Out-Patient _____ Intensive Out-Patient ____In-Patient _____ Refer to LIP diagnosis and placement. _____ Refer to medical officer for evaluation of need for detoxification. 1 of 2 3-11 _____ Refer to the following 12 step program meetings (AA/NA/Other____________). Recommend ______ meeting(s) per week for _______ week(s)/month(s). _____ Refer to Fleet Mental Health for psychiatric evaluation. Specify reason: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ _____ Other: Specify referral source and reason: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Amenability to Potential for further productive service recommendations: with recommended program: ___ Good ___ Good ___ Fair ___ Fair ___ Poor ___ Poor Client Signature: _______________________ Date:____________ Counselor Signature:______________________ Date:____________ Client Name:___________________ Client SSN:_________________ 2 of 2 3-12 DISPOSITION OF REFERRED PROBLEMS Problem:________________________________________________________ ________________________________________________________________ Comments:_______________________________________________________ ________________________________________________________________ Referral Agency:_________________________________________________________ Client Signature:____________________________ Date:_____________ Counselor Signature:_________________________ Date:_____________ Problem:________________________________________________________ ________________________________________________________________ Comments:_______________________________________________________ ________________________________________________________________ Referral Agency:_________________________________________________________ Client Signature:____________________________ Date:_____________ Counselor Signature:_________________________ Date:_____________ Problem:________________________________________________________ ________________________________________________________________ Comments:_______________________________________________________ ________________________________________________________________ Referral Agency:_________________________________________________________ Client Signature:____________________________ Date:_____________ Counselor Signature:_________________________ Date:_____________ Client Name: ________________________ SSN: _______________ 3-12 1 of 1 3-13 FAMILY AND CULTURAL HISTORY 1. Describe your parents (and step-parents) and your present/past relationship with each parent (and step-parent). ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. Describe your brothers, sisters, and step-siblings, (include ages). _________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Do the people with whom you reside abuse alcohol or drugs? Yes______ No______ 4. How is your present marriage? Include a description of your relationship with your spouse. _______________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 5. If you have been married, how many times?______ 6. Does your spouse have difficulty with alcohol, drugs, or other problems? Yes___ No___ 7. What family problems are of concern to you? Also, explain any concerns you may have about a specific family member. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Client Signature: ____________ Date: ____________ Client Name:_______________________ Client SSN:_________________ 1 of 2 3-14 8. Has any member of your family ever been treated for mental illness or substance abuse? Yes___ No___ If yes, explain: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Additional comments: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Client Signature: Date: __________ Client Name:_______________________ Client SSN:_________________ 2 of 2 3-15 EDUCATION AND WORK HISTORY 1. Are you currently taking college courses? Yes___ No___ 2. What was your usual job or occupation prior to joining the service?________________________________________________________ 3. Were you ever fired or relieved? Yes___ No___ If yes, explain?________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. What trouble, if any, did/do you have with your job? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5. Has your job performance been affected by your use of alcohol or drugs? Yes___ No___ If yes, explain:________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Client Signature: Date: __________ Client Name:_______________________ Client SSN:_________________ 1 of 1 3-16 MILITARY HISTORY 1. Why did you join the military?_______________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. If service is broken, what did you do between enlistments and why did you re-enter? _____________________________________ ________________________________________________________________ ________________________________________________________________ 3. Are you currently pending separation or retirement from the service? Yes___ No___ 4. If pending separation or retirement from the military, what are your future plans? _________________________________________ ________________________________________________________________ ________________________________________________________________ 5. Do you have any combat experience? Yes___ No___ 6. Are you concerned that you may not be allowed to resume your full military occupational specialty duties because of problems related to alcohol or drugs? Yes___ No___ If yes, explain:________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Client Signature: Date: ______________ Client Name:_______________________ Client SSN:_________________ 1 of 1 3-17 SOCIALIZATION, SELF-CONCEPT AND COMMUNICATIONS HISTORY 1. How many close friends do you have? ___________ 2. Are you satisfied with your current circle of friends? Yes___ No___ 3. Do alcohol or drugs make it easier for you to socialize? Yes___ No___ 4. What are your personal strengths? _________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5. Would you describe yourself as a loner? Yes___ No___ 6. Are you still experiencing feelings of grief, hurt or sadness over the loss of a significant person in your life? Yes___ No___ 7. Do you have trouble speaking up and asserting yourself? Yes___ No___ 8. Do you have outbursts or loss of control of your temper? Yes___ No___ Client Signature: Date: __________ Client Name:_______________________ Client SSN:_________________ 1 of 1 3-18 FINANCIAL HISTORY 1. What was your income last year? ______________ 2. Have you been in trouble for spending too much money or spending money inappropriately? Yes___ No___ If yes explain:________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Sources of income last year: ____Job ____Savings ____Family ____Friends ____Navy Relief ____Public Assistance/Welfare ____Other_____________________ Client Signature: Date: __________ Client Name:_______________________ Client SSN:_________________ 1 of 1 3-19 SPIRITUALITY AND RELIGION HISTORY 1. Do you have a religious preference? Yes___ No___ Explain:________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. Would you like to visit with a chaplain for the purpose of exploring religious/spiritual issues while you are here? Yes___ No___ Client Signature:__________________________ Date: __________ Client Name:________________________ Client SSN:______________ 1 of 1 3-20 LEGAL HISTORY 1. Do you have any current legal problems or concerns (military or civilian)? Yes___ No___ If yes, explain:________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. Do you have any pending military or civilian court dates? Yes___ No___ If yes, explain:________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Have you ever been arrested? Yes___ No___ If yes, please explain:________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. Please indicate the number of times you have been arrested for the following alcohol or drug related offenses: Date : Infraction Blood Alcohol Content (Mo/Yr) (number of times) (if known) ____ DUI/DWI:_________________________ BAL:__________________ ____ Public Intoxication:_____________ BAL:__________________ ____ Drunk and Disorderly:____________ BAL:__________________ ____ Assault:_________________________ BAL:__________________ ____ Other:___________________________ BAL:__________________ Client Signature: Date: ____________ Client Name:_______________________ Client SSN:_________________ 1 of 1 3-21 EMOTIONAL AND BEHAVIORAL HISTORY 1. Are you now seeing or have you ever been seen in the past by a psychiatrist, psychologist, social worker, or other mental health professional? Yes___ No___ 2. Do you have difficulty performing sexually unless you are "high" on alcohol or other drugs? Yes___ No___ 3. Have you ever heard voices that other people have not heard? Yes___ No___ 4. Have you ever seen things that other people have not seen? Yes___ No___ 5. Have you ever intentionally set a fire? Yes___ No___ 6. Have you ever been cruel to animals? Yes___ No___ 7. Have you been in many fights? Yes___ No___ 8. Have you ever run away from home? Yes___ No___ 9. Are you currently experiencing crying spells? Yes___ No___ 10. Do you believe that you have a problem handling stress? Yes___ No___ 11. Have you recently experienced sleep difficulties? Yes___ No___ 12. Are you currently having feelings of helplessness or hopelessness? Yes___ No___ Client Signature: Date: __________ Client Name:_______________________ Client SSN:_________________ 1 of 2 3-22 13. Are you currently having thoughts of hurting someone else? Yes___ No___ If yes, explain: ______________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 14. Have you ever contemplated, threatened, or attempted suicide or self-injury? Yes___ No___ If yes, explain: ______________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 15. Have you ever received a psychiatric diagnosis of any kind? Yes___ No___ If yes, explain: ______________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Client Signature: Date: _________ Client Name:________________________ Client SSN:_______________ 2 of 2 3-23 INDIVIDUAL TREATMENT PLAN Problem #:______ Problem Statement :__________________________________________________________________ Goal (s) Objectives (includes methods and frequency) Client Initial Objective Dates Open Target Close Staff Implementer Case Manager Signature:_________________________________________Date:___________ Date Initials Date Initials Date Initials Date Initials Date Initials Date Initials Client Signature (Date Open): Client Signature (Date Closed): _______________ Counselor Signature: Date: __________ Supervisor Signature: Date: LIP Signature:______________ Date: ________ Client Name: Client SSN: ______________________________ 1 of 1 INDIVIDUAL TREATMENT PLAN COVER SHEET Diagnosis/Diagnostic Impression: 1. _______________________________________________________ 2. _______________________________________________________ 3. _______________________________________________________ 4. _______________________________________________________ 5. _______________________________________________________ MASTER PROBLEM LIST Date Problem # Description of Clinical Problems Codes Codes: T=Current Treatment Program R=Referred Estimated Length of Treatment: Days Estimated Completion Date: ____________ Client Signature: Date: _________ Counselor Signature: Date: _________ Client Name: Client SSN:__________________ 1 of 1 3-24 INFORMATION RELEASE AUTHORIZATION I, _________________________________(client's name) hereby authorize _____________________________(program name), its director, or designee, to release information contained in my client record(s) to the below listed individual(s) or organization(s) and only under the conditions listed below: 1. Name of person(s) or organization(s) to whom disclosure is to be made: ______________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 2. Specific type of information to be disclosed: ________ ___________________________________________________________ ___________________________________________________________ 3. The purpose and need for such disclosure: ____________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 4. This consent is subject to revocation at anytime. 5. Without express revocation this consent expires for the following specified reasons: A. Date:_____/_____/_____ B. Event: _________________________________________ C. Condition: _______________________________________ _____________________________ _______________________ Client's Signature Date Signed _____________________________ _______________________ Witnessed By Date Witnessed Client Name: Date: _________ 1 of 1 3-25 SIGNIFICANT OTHER ASSESSMENT FORM DRUG/ALCOHOL This form is being sent to you with the permission of _____________________. This form has been developed for use as part of overall evaluation of the client for drug or alcohol dependency. Please check the most appropriate response or fill in the answer. Choose only one response per question unless otherwise instructed. Thank you for your help. A signed Consent Form must be obtained from the client prior to presenting this form to the client's significant other. A. Alcohol or other mood-altering chemical use . During the past year, was the client having problems with any of these drugs? (Be sure to answer each item) Don't Yes No Know 1. Alcohol (beer, wine, liquor) ___ ___ ___ 2. Sedatives (sleeping pills, tranquilizers) ___ ___ ___ 3. Stimulants (pep pills, diet pills, speed) ___ ___ ___ 4. Opiates (pain pills, heroin) ___ ___ ___ 5. Hallucinogens (LSD, PCP) ___ ___ ___ 6. Marijuana ___ ___ ___ 7. Other substances ________________________________

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