SERENITY FOUNDATION OF TEXAS

Substance Abuse Treatment Facility

1546 North 2nd Street, Abilene, TX, 79601-5623
325-673-6489
TREATMENT PLAN___________________________________________________________________________________
CLIENT NAME: MELISSA LEA EDWARDS CLIENT NUMBER: 2092599 DISCHARGED: 12/17/2022
LOCATION: 100232 ABILENE INPATIENT GENDER: FEMALE
DOB: 11/08/1973 DATE: 11/21/2022
STRENGTHS & LIMITATIONS___________________________________________________________________________
STRENGTH: “ I Have a zest for life"
NEED: "I need to cry. I need to let go."
ABILITIES: "I am a light at times, and I am very optimistic"
PREFERENCE: " I don’t like to hold on to feelings, I am a talker"
LIMITATIONS: " My mouth and my ego get in the way"
_________________________________________________________________________________________________

• Client has discharge/aftercare needs-TREAT_______________________________________________________

• Client has substance abuse issue- TREAT__________________________________________________________

• Client has a mental health issue-TREAT___________________________________________________________

• Client has a family/social issue- TREAT___________________________________________________________

• Client has a legal issue-TREAT__________________________________________________________________

• Client has employment needs-TREAT____________________________________________________________

• Client has housing needs-TREAT________________________________________________________________

TREATMENT TEAM MEMBERS & ROLES__________________________________________________________________

Mary Christie - LCDC (Counselor)
Trina O'Neal- CL (Primary Counselor)
__________________________________________________________________________________________

Client Signature______________________________________

Legally Authorized
Representative (LAR)
Signature: __________________________________________

Staff Signature: _____________________________________

1
AUDIT INFORMATION________________________________________________________________________________
Created By: O’Neal, Trina Created Date: 11/21/2022.
Last Saved By: O’Neal, Trina
Last Saved Date: 12/16/2022
PROBLEM DETAIL____________________________________________________________________________________

Problem Problem Statement Problem Description Problem Date Status Change

Number Date
1 Client has discharge/aftercare needs “I need housing and support” 11/21/2022 12/16/2022

1. GOAL: Identify healthy living environment and attend aftercare through rose counseling for 6 weeks

Type Description Date Status Frequency Units Of Duration In

Change Service Hours
Date
Objectiv • identify healthy living 11/21/2222 12/16/2222 X X X
e environment.
• arrange to attend 11/21/2222 12/16/2222
aftercare

Strateg • help client identify 11/21/2222 12/16/2222 Weekly 1 1

y housing that is
conducive to
recovery

PROBLEM DETAIL____________________________________________________________________________________

Problem Problem Statement Problem Description Problem Date Status Change

Number Date
2 Client has a substance use issue “I have been trying to get 11/21/2022 12/16/2022
clean forever…I just can’t”

2. GOAL: Get clean!

Type Description Date Status Frequency Units Of Duration In

Change Service Hours
Date
Objectiv • Identify 1-3 issues that 11/21/2222 12/16/2222 X X X
e contribute to
substance use. 11/21/2222 12/16/2222
• Identify 1-3 coping
skills to manage
cravings/impulses.

2
 • Attend 11/21/2022 12/16/2022
groups/lectures on X X X
topics pertaining to
self-improvement.
• Identify reasons you 11/21/2022 12/16/2022
chose to stop using. X X X
• Identify the role
substance use has to 11/21/2022 12/01/2022
my PTSD related to
childhood. X X X
• Learn about NA/AA
and verbalize an 11/21/2022 12/16/2022
understanding of 3
principles. X X X
• Attend daily NA/AA
meetings and 11/21/2022 12/16/2022
establish a sponsor
Strateg • Counselor will 11/21/2222 12/16/2222 Weekly 1 1
y collaborate with
client to develop a
better understanding
of issues that
influence substance
use.
• Counselor will aid 11/21/2022 12/16/2022 Weekly 1 1
client with coping
skills.
• Groups will be
facilitated pertaining 11/21/2022 12/16/2022 Daily 2 1
to recovery from
substance use Assess
• client’s substance
use as a means of 11/21/2022 12/16/2022
coping with Weekly 1 1
childhood trauma.
• Facilitate info
regarding 12 step 11/21/2022 12/16/2022
programs through
meetings, counseling daily 1 1
sessions, and
lectures

PROBLEM DETAIL____________________________________________________________________________________

Problem Problem Statement Problem Description Problem Date Status Change

3
Number Date
3 Client has mental health issues “I have PTSD and anger” 11/21/2022 12/16/2022

3. GOAL: Mourn and cope

Type Description Date Status Frequency Units Of Duration In

Change Service Hours
Date
Objectiv • identify one to three. 11/21/2022 12/16/2022 X X X
e coping skills to better
manage emotional 12/16/2022
distress identify one
• to three.
coping skills to better
manage trauma
issues identify the 11/21/2022 12/16/2022
• cause or causes of
the grief I'm
experience of grief,
and one to three
coping skills for each
identified issue 12/16/2022
• attend seeking 11/21/2022
safety.
groups and
participate in learning 11/21/2022
3 to 5 new skills to
cope with
effects of past
traumas

4
 • counselor will work 12/16/2022
Strategy with client to identify
math methods and Weekly 1 1
assignments to work
towards
reconciliation of
grief issues 11/21/2022
• counseling staff will 12/16/2022
facilitate group daily
counseling 2
specifically devoted 1
to processing and
attempting
resolution of trauma
issues and identify
and practice
effective coping skills

PROBLEM DETAIL____________________________________________________________________________________

Problem Problem Statement Problem Description Problem Date Status Change

Number Date
4 Client has family or social issue “I don’t have any support” 11/21/2022 12/16/2022

4. GOAL: Stay in the program and build a support group

Type Description Date Status Frequency Units Of Duration In

5
 Change Service Hours
Date
Objectiv • attend groups and 11/21/2222 12/16/2222 X X X
e lectures focusing on
relationships and be
able to identify three
to five skills social
behaviors and
characteristics of a
healthy family social
system
• Verbalize a better 11/21/2222 12/16/2222 X X X
understanding of
dysfunctional
family
roles in life the
damage they cause
and be able to identify
two or be corrective
measures
Strateg • counseling staff will 11/21/2222 12/16/2222 Daily 2 1
y present and facilitate
lectures and process
groups on building
healthy relationships
and positive
interactions
• counseling staff will 11/21/2022 12/16/2022 Daily 2 1
present and facilitate
and process groups
relating to information
about distal family
systems

6
PROBLEM DETAIL____________________________________________________________________________________

Problem Problem Statement Problem Description Problem Date Status Change

Number Date
5 secure employment “I am unemployed” 11/21/2022 12/16/2022

5. GOAL: secure employment

Type Description Date Status Frequency Units Of Duration In

Change Service Hours
Date
Objectiv • identify employment 11/21/2222 12/16/2222 X X X
e skills and identify
employment
opportunities

Strateg • peer coaches and 11/21/2222 12/16/2222 weekly 1 1

y other staff will work
to identify.
employment
opportunities and
assist in contacting
employers and apply
for employment

SUMMARY_________________________________________________________________________________________

The client has achieved the treatment goals in the individual treatment plan and has resolved the problem that justified
admission to the present level of care. She appears physically healthy and has a much more positive outlook on her
future. She appears eager to achieve her goals and her sense of self-worth has increased dramatically. She has begun to
build a strong network of resources and has a long-term plan that will be instrumental in her sobriety. The client is
ready for discharge and her prognosis is excellent.