Addiction Awareness OSCA 11-036 response - REDACTED.pdf

Addiction Awareness, LLC Treatment Incident Report
Missouri Department of Probation and Parole
Client/Offender Name:
________________________________________________
Counselor : _______________________________ Date: __________________
Incident(s) affecting treatment:
Positive UA/BA ______ Association ______ Incarceration _____ Medical _____
Work change ______ Family Issue _____ Demographics____ Sanction ____
PO transfer ______ Reporting change _____ Discharge ______
Date when the incident did or will occur:
________________________
Other issues to consider regarding incident: ____________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
If a relapse: Alcohol/Drug Did they admit? __________________
Statement from client: ______________________________________________________
________________________________________________________________________
________________________________________________________________________
How much was used if known and over what time frame? _________________________
________________________________________________________________________
How was the relapse discovered?
__________________________________________
Comments regarding above incidents being reported:_____________________________
________________________________________________________________________
________________________________________________________________________
Other Information necessary for treatment team: ________________________________
________________________________________________________________________
________________________________________________________________________
Counselor staffing detailed recommendations:
Counselor (or Counselor Supervisor) Signature
Date