Objective 2: Provide
individual counseling services to youth and adults admitted to the program.
All clients will be seen for individual sessions for a
minimum of
one per week. More sessions may be
scheduled if identified as
necessary not to exceed 10 (ten) hours per week. Progress notes
will be
completed within 24 hours of the session using the SOAP format.
The
SOAP (Subjective; Objective; Assessment and Plan) format
will be
completed using the following guidelines:
S
(subjective): the verbal utterances of the client, the focus of the
session as determined by the treatment plan;
O
(objective): what can be seen by anyone in the room – the
client’s posture, affect, mood, physical movements, eye contact
A
(assessment): the counselor’s assessment of change in the
client’s behaviors/attitude/progress with treatment goals/insight
gained into identified problems
P (plan): the plan for
behaviors to occur between this session and
the
next according to the treatment plan
All
SOAP notes completed by intern/practicum students will be
reviewed and countersigned by the LADC supervisor.
Activity 1: Provide a minimum of one (1)
hour of individual counseling per week. Each session is not to exceed
3 (three) hours duration and no more than 10 (ten) hours per week total
session hours will be conducted.
Person
Responsible: Assigned
Counselor
Completion Ongoing
Date:
Document: Treatment
Contract
AccuCare Progress Note (using SOAP format)
Mode of
Evaluation: LADC
Supervisor
Quality Assurance Committee
Activity 2: When applicable, provide group
sessions to clients in regularly scheduled sessions of fewer than nine
contact hours per week.
The ratio of staff to group members
shall not exceed 1:8.
Person(s)
Responsible: Counselor(s)
Completion
Date: On going (group length to be
determined at the outset)
Documents: Treatment Contract
Progress Note in
SOAP format for each session
Mode of
Evaluation: Agency Executive Review
Program Coordinator
Review
Quality Assurance
Committee
