SUD Treatment Plan Working w/custom inputs

Substance Use Disorder Service Plan
[checkbox name="variable_1" value="for" memo="click to include pt name"] [conditional field="variable_1" condition="(variable_1).is('for')"] [text memo="patient name"][/conditional]	
Date:[date name="date" default=""]
MRN#:[text name="mrn" default=] 		
DX:[checkbox name="DX" value="F10.10 Alcohol abuse, uncomplicated|F10.20 Alcohol dependence, uncomplicated|F11.20 Opioid dependence, uncomplicated|F15.20 Other stimulant dependence, uncomplicated|"]

Referrals for needed adjunct services or Recovery Support Services necessary for this plan
[checkbox name="Wellbriety_Referral" value="Wellbriety Program"]
[checkbox name="Transportation_Referral" value="Transportation"]
[checkbox name="Wellness_Center_Referral" value="Wellness Center Referral"]
[checkbox name="MAT_Program" value="MAT Program"]
[conditional field="MAT_Program" condition="(MAT_Program).is('MAT Program')"] [text memo="type date of appointment with MAT Coordinator" text area=""][/conditional]
[checkbox name="Probation_Officer_Refer" value="Probation Officer"]
[conditional field="Probation_Officer_Refer" condition="(Probation_Officer_Refer).is('Probation Officer')"] [text memo="Name and contact information of probation officer" text area=""][/conditional]

Recovery Planning Team 
[checkbox name="Recovery_Planning value="Patient|BH Provider|Recovery Coach|Significant Other/Family|Other"] [conditional field="Referrals_Needed" condition="(Referrals_Needed).is('Probation Officer')"] [text memo="type name of probation officer" text area=""][/conditional]

Community Supports[checkbox name="Community_Supports" value="AA|NA|Wellbriety|Faith Based Support"]

ASAM Dimensions Service Needs Assessment

Dimension 1.[select name="Dimension_1" value="Defer-Will monitor dimension, no current needs identified|Refer-Patient will be referred to medical provider to evaluate detox/withdrawal risk |Treat-Patient has identified withdrawal symptoms that warrant care"]
Dimension 2.[select name="Dimension_2" value="Defer-Will monitor dimension, no current needs identified|Refer-Patient presents with medical conditions that may impact recovery|Treat"]
Dimension 3.[select name="Dimension_3" value="Defer-Will monitor dimension, no current needs identified|Refer-Patient will be referred for a mental health evaluation|Refer-Patient will be referred to psychiatric care|Treat-Patient will be treated for mental health/co-occurring condition that impacts functioning"]
Dimension 4.[select name="Dimension_4" value="Defer-Will monitor dimension, no current needs identified|Refer-Patient will be referred for specialty care to support motivational enhancement|Treat-Patient currently in the Pre-contemplation stage of change and will require motivational enhancement to support treatment engagement|Treat-Patient is in the Contemplation Stage of Change and will benefit from psychoeducation and brief interventions to support motivation|Treat-Patient is in the Preparation Stage of Change and is motivated to follow these treatment recommendations|Treat-Patient is in the action stage of change and will continue to work through their treatment plan and recovery development|Treat-Patient is in the maintenance Stage of Change and will continue to reinforce recovery behaviors and skills to promote healthy lifestyle"] 
Dimension 5.[select name="Dimension_5" value="Defer-Will monitor dimension, no current needs identified|Refer-Patient is at risk for relapse and will require specialty referral to higher level of care|Treat-Patient will be treated with interventions promoting relapse prevention skills and positive adaptive behavior modifications|Treat-Patient has demonstrated successful use of relapse prevention skills, and we will reinforce this area"]
Dimension 6.[select name="Dimension_6" value="Defer-Will monitor dimension, no current needs identified|Refer-Patient will be referred for support in their recovery environment|Treat-We will work on development/reinforcement of their recovery environment|Treat-Patient is in need of stable housing in this area|Treat-Patient would benefit from maintenance of their recovery environment and has developed positive recovery resources"]