NCCAP ADC cheat sheet

Screening determines whether a full assessment is warranted; it is brief, standardized, and administered before any diagnosis or treatment plan.

Intake captures identifying data, presenting problem, substance use history, prior treatment, medical and psychiatric history, and legal status.

Informed consent for screening must cover purpose, procedures, limits of confidentiality, and the right to refuse or withdraw.

ASAM Criteria dimension 1 (intoxication/withdrawal potential) and dimension 2 (biomedical conditions) are screened at intake to flag medical urgency.

Suicide and violence risk screening is a required intake element; a positive screen triggers a full risk assessment, not a disposition.

Confidentiality at intake is governed by 42 CFR Part 2 for substance use records, which is stricter than HIPAA and requires specific written consent for disclosure.

Screeners must be validated for the population served; cutoff scores from one population do not transfer automatically to another.

A client may be screened as inappropriate for a program level and referred elsewhere; screening does not obligate admission.

Assessment is ongoing and multidimensional; the six ASAM dimensions are intoxication/withdrawal, biomedical, emotional/behavioral/cognitive, readiness to change, relapse potential, and recovery environment.

DSM-5-TR substance use disorder severity is graded by number of criteria met in 12 months: 2-3 mild, 4-5 moderate, 6 or more severe.

Tolerance and withdrawal are not counted as criteria when the substance is taken solely under appropriate medical supervision.

A diagnosis requires clinically significant impairment or distress; mere use or legal consequence alone is insufficient.

Differential diagnosis must rule out other conditions that mimic intoxication or withdrawal, including hypoglycemia, head injury, sepsis, and psychiatric disorders.

Collateral information from family, employers, or records supplements self-report, which is subject to denial, minimization, and recall error.

Standardized instruments (e.g., AUDIT, DAST, ASI, CAGE) support but do not replace clinical interview and judgment.

Co-occurring mental health disorders must be assessed concurrently; integrated treatment is the expected standard rather than sequential care.

The treatment plan is derived from assessment findings, states measurable goals and objectives, and names specific interventions, responsible staff, and target dates.

Level of care is determined by matching ASAM dimension findings to the ASAM Criteria levels: outpatient, intensive outpatient, residential, and medically managed inpatient.

Goals are broad desired outcomes; objectives are specific, measurable, time-bound steps that demonstrate progress toward the goal.

The plan is developed with the client, not for the client; client participation in goal setting increases engagement and is documented.

Plans are reviewed and revised when the client changes level of care, meets or fails objectives, or experiences a significant change in condition.

Problem statements in the plan should be written in behavioral, observable terms rather than as labels or judgments.

Transfer and discharge planning begins at admission, including anticipated continuing care and recovery support linkages.

Documented rationale is required when the chosen level of care departs from the ASAM Criteria recommendation.

Motivational interviewing uses open questions, affirmations, reflections, and summaries, with the goal of eliciting change talk rather than arguing for change.

The stages of change are precontemplation, contemplation, preparation, action, maintenance, and relapse; interventions are matched to stage.

Cognitive behavioral approaches target the identification and restructuring of thoughts and beliefs that trigger substance use.

Relapse prevention distinguishes a lapse from a relapse and treats a lapse as a learning event rather than a treatment failure.

Group counseling requires ground rules on confidentiality, attendance, and mutual respect; confidentiality limits in group must be stated explicitly.

Service coordination includes linking clients to medical, psychiatric, housing, employment, and legal services, and confirming that linkages occurred.

Counselors document each session with date, type, duration, interventions used, client response, and plan for next contact.

Contingency management reinforces verified abstinence or treatment attendance with defined, pre-specified rewards.

Education content on substance use disorder should present it as a chronic, treatable condition with relapse risk, not a moral failing.

Family education covers enabling behaviors, boundaries, communication skills, and the availability of family support programs such as Al-Anon and Nar-Anon.

Confidentiality rules limit what can be shared with family; disclosure requires the client's written consent or an applicable exception.

Overdose education includes recognizing signs (pinpoint pupils, slowed breathing, unresponsiveness) and naloxone administration and calling emergency services.

Community education includes reducing stigma, describing local treatment and recovery resources, and explaining Good Samaritan protections where they apply.

Health literacy and language must be matched to the audience; teach-back confirms comprehension better than asking whether the material was understood.

Education about medication for opioid use disorder should cover that these medications are evidence-based and reduce mortality.

The record must be accurate, timely, legible, objective, and complete; entries are dated and authenticated by the author.

Corrections are made by drawing a single line, writing the correction, initialing, and dating; errors are never obliterated or whited out.

Late entries are labeled as late and include the date of entry plus the date of the service being documented.

Records are retained per federal and state requirements; many jurisdictions require retention for a defined period after the last service, often years not months.

Release of information requires a written, signed, time-limited consent specifying the recipient, the information to be disclosed, and the purpose.

Progress notes should link to the treatment plan and describe client response to intervention, not just the topic discussed.

Subjective opinion should be labeled as such; direct quotes are used for statements of clinical significance.

Records may be subpoenaed; legal counsel should be consulted before release in response to a subpoena absent client consent.

Confidentiality is the default; exceptions include imminent danger to self or others, suspected child or elder abuse, and court order, each with jurisdiction-specific reporting duties.

Duty to warn or protect is triggered by a credible threat to an identifiable person and requires the steps specified by state law.

Dual relationships that risk exploitation of the client should be avoided; unavoidable ones require disclosure, consultation, and documentation.

Scope of practice limits counselors to services within their training and credentials; out-of-scope needs are referred.

Boundaries around gifts, self-disclosure, and physical contact are set by the counselor's code of ethics and agency policy, and decisions are documented.

Competence includes cultural competence and continuing education; counselors do not treat populations outside their competence without supervision or training.

Impaired practice, whether from substances or untreated impairment, requires reporting through the channels defined by law and the certifying body.

Ethical decision-making models typically proceed through identifying the problem, consulting the code, considering options, consulting others, deciding, and documenting.

Case management functions include assessment, planning, linking, monitoring, and advocacy; the case manager coordinates rather than delivers all services.

Referrals should be matched to assessed need and confirmed by follow-up contact; an unconfirmed referral is not a completed linkage.

Warm handoffs, in which the client is connected directly to the receiving provider, improve engagement over passive referral lists.

Release of information must be in place before a case manager can exchange information with another provider.

Case managers document referral date, receiving agency, reason, and outcome, including whether the client attended.

Barriers to referral completion include transportation, cost, waitlists, documentation requirements, and stigma; each barrier should be addressed in the plan.

Care coordination with courts, child welfare, and employers is bounded by the client's consent unless a legal mandate applies.

Case closure includes a summary of services, outcomes, and continuing care recommendations.

The counselor confirms that referrals resulted in service delivery; coordination is not complete until the linkage is verified.

Documentation of coordination includes who was contacted, when, what information was exchanged, and the resulting plan.

Multidisciplinary team meetings require that only the minimum necessary information be shared for the purpose of care.

When a client misses appointments, the counselor documents outreach attempts and the client's response before closing the case.

Counseling techniques are selected to match the client's stage of change; confrontation is not used to force action in precontemplation.

Service coordination with medication providers includes monitoring adherence and reporting side effects or concerns promptly.

Withdrawal risk is substance-specific: alcohol, benzodiazepine, and barbiturate withdrawal can be life-threatening and require medical management.

Opioid withdrawal is highly uncomfortable but rarely fatal; the assessment still determines the appropriate level of care.

Assessment instruments should be administered and scored according to their published instructions; deviations reduce validity.

Diagnosis is made by a qualified professional within their scope; screening results alone do not establish a diagnosis.

The assessment documents strengths and supports as well as problems, since these inform the treatment plan.

The minimum data set in a clinical record includes identifying information, consent documents, assessments, plans, progress notes, and discharge summary.

Records must be stored securely with access limited to authorized staff; electronic records require unique user credentials.

A court order can override a client's refusal to consent to disclosure, but 42 CFR Part 2 requires specific procedures and, in some cases, a court order meeting particular criteria.

Progress notes written in the SOAP format separate subjective report, objective findings, assessment, and plan.

Discharge summaries state the reason for discharge, services provided, progress toward goals, and referrals made.

Informed consent must be obtained before treatment and renewed when the nature of services changes materially.

Counselors do not accept gifts of substantial value, and any accepted gift is documented with rationale.

Supervision of unlicensed staff requires the supervisor to review and co-sign documentation as required by regulation.

Ethical violations are reported to the certifying or licensing board; the duty to report is separate from the duty to warn.

Client records and identifying information must not be discussed in public or on unsecured channels.

A referral should specify the reason, the receiving provider, and the information the client needs to bring.

Follow-up on referrals is time-bound; the plan states when the case manager will confirm attendance.

Advocacy includes helping clients navigate eligibility systems for Medicaid, housing, and disability benefits.

Continuity of care requires that the receiving provider have enough information to continue treatment without repeating the full assessment.

Intake documentation includes the client's stated goals, which anchor later treatment planning.

Screening tools should be brief enough to administer routinely and sensitive enough to avoid missing likely cases.

A positive screen for co-occurring disorders prompts referral for a full psychiatric assessment.

Intake staff explain program rules, fees, hours, and expectations, and document that the explanation occurred.

Education on relapse includes identifying personal triggers, warning signs, and a written coping plan.

Family members are taught that recovery is a process and that their own support needs are legitimate.

Community presentations should include accurate referral information and clear limits on what the presenter can offer.

Materials should be reviewed for readability and cultural relevance before distribution.

Each objective should be measurable enough that two reviewers would agree whether it was met.

The plan identifies who is responsible for each intervention, not only what the intervention is.

Client disagreement with the plan is documented along with the clinical rationale for the recommended approach.

Referrals for services outside the program are listed in the plan with target dates.