Personalized Substance Use Recovery Plan

Patient Information

Name: ________________________
Date: _________________________
Provider: ______________________

Treatment Goals

• Primary substance(s) of concern: ____________________
• Target quit/reduction date: _________________________
• Long-term recovery objectives: ______________________

Treatment Components

1. Medical Management

• Medication-assisted treatment (if applicable)
• Regular medical check-ups
• Vital signs monitoring
• Laboratory testing schedule

2. Counseling Schedule

• Individual therapy: _____ sessions per week/month
• Group therapy: _____ sessions per week/month
• Family therapy (if applicable): _____ sessions per month

3. Support Systems

• Emergency contact: ____________________
• Support group meetings (type/frequency): ________________
• Sponsor (if applicable): ____________________

4. Relapse Prevention Strategies

1. Identified triggers:

   • ---

   • ---

   • ---

2. Coping mechanisms:

   • ---

   • ---

   • ---

Crisis Management Plan

• 24/7 Crisis Hotline: ____________________
• Emergency Services: 911
• Treatment facility: ____________________

Monitoring and Progress

• Weekly/monthly goals: ____________________
• Progress indicators: ____________________
• Next review date: ____________________

Agreement

I understand and agree to participate in this treatment plan:

Patient Signature / Date

Provider Signature / Date