NAADAC NCAC I key terms

A structured evaluation that gathers biological, psychological, and social information about a client to understand substance use and mental health needs and to guide diagnosis and treatment planning.

A set of standardized guidelines used to match a person's substance use and related medical, psychological, and social needs to the appropriate level and intensity of care.

A diagnosis describing a pattern of substance use that causes significant impairment or distress, rated mild, moderate, or severe based on how many criteria are met.

A brief, standardized process used to identify whether a person may have a substance use or mental health problem and needs a fuller assessment.

A structured observation and description of a client's appearance, mood, thought process, cognition, and judgment, used to summarize current psychological functioning.

A direct inquiry into a client's suicidal thoughts, plans, access to means, and history of self-harm, used to judge immediate danger and plan safety steps.

Medical and supportive care for physical symptoms that occur when a dependent person stops or reduces substance use, ranging from monitoring to medically supervised detoxification.

Screening, Brief Intervention, and Referral to Treatment: a public health approach that identifies risky substance use early, offers short counseling, and refers people to further services.

A written plan developed with the client that states identified problems, goals, measurable objectives, services to be provided, and who is responsible for each action.

A specific, observable statement of what a client will do or achieve within a stated time frame so that progress can be judged objectively.

The intensity and setting of treatment, such as outpatient, intensive outpatient, residential, or medically monitored inpatient care, selected to match the client's assessed needs.

A plan made before discharge that describes ongoing services, supports, and appointments intended to help the client maintain treatment gains after formal care ends.

A scheduled reassessment of whether the client's goals and objectives are being met and whether the plan should be continued, updated, or changed.

An approach in which the client's values, preferences, and goals shape the treatment plan, with the counselor acting as a collaborator rather than an authority.

A direct, personal transfer of a client to another provider or service, often by phone or in person, so the connection is made before the client leaves.

The process of connecting a client to another service, provider, or resource that can meet a need outside the current program's scope or expertise.

A written, time-limited authorization signed by the client that permits a named provider to share specified health information with another named person or organization.

Coordinating a client's care across services, including linking to resources, advocating for needs, and monitoring whether services are delivered and effective.

A group of professionals from different disciplines, such as counseling, medicine, and social work, who share information and plan care together for a client.

Organizing and sharing information among providers and services so that a client receives consistent, non-duplicated care across settings and over time.

A collaborative counseling style that explores and strengthens a client's own reasons for change while respecting autonomy and avoiding argument and confrontation.

A model describing readiness to change as moving through precontemplation, contemplation, preparation, action, and maintenance, with interventions matched to the person's current stage.

A structured counseling approach that helps clients identify and change unhelpful thoughts and behaviors linked to substance use and other problems.

A set of strategies that help clients recognize high-risk situations, manage cravings, and respond to lapses without returning to harmful substance use.

The working relationship between counselor and client, built on trust, agreement about goals, and collaboration on the tasks of treatment.

Teaching clients and families about substance use, mental health, treatment, and recovery so they can make informed decisions and support behavior change.

Structured information and support offered to family members about addiction, recovery, communication, and resources, often helping them set healthy boundaries.

Negative beliefs and social devaluation attached to substance use or mental health conditions that can discourage people from seeking help or continuing treatment.

A dated record of a service encounter describing the client's status, the intervention provided, the client's response, and the plan for next steps.

A progress note format organized into Subjective, Objective, Assessment, and Plan sections, used to record a clinical encounter clearly and consistently.

Federal regulations that protect records of people receiving substance use disorder treatment and require specific written consent before most disclosures.

The ethical and legal duty to protect client information from unauthorized disclosure, with limited exceptions such as client consent, imminent danger, or mandated reporting.

A client's voluntary agreement to treatment or to share information after being told the purpose, risks, benefits, alternatives, and the right to withdraw.

A situation in which a counselor has another significant role with a client, such as business partner or friend, that can impair objectivity and exploit the client.

The limits that define a safe, appropriate relationship between counselor and client, protecting the client's welfare and the integrity of treatment.

A legal requirement for counselors to report suspected child abuse, neglect, or other specified harm to designated authorities, even without the client's consent.

The range of services and activities a counselor is trained, credentialed, and legally permitted to perform, based on education, certification or licensure, and law.

A structured process for resolving ethical dilemmas by identifying the problem, consulting codes and laws, considering options, and choosing and reviewing an action.

The ability to understand and respond respectfully to clients' cultural backgrounds, values, and experiences, and to adapt services so they fit the person.