Continuing Care Plan Template

[text name="variable_1" default="Insert Patient Name "] has the current diagnosis of:
[text name="variable_1" default="Insert Patient Name "] is reccomended to follow up with [checkbox name="variable_1" value="Mental health therapy| Psychiatric services| SUD| Mat| Family Therapy| Case management | medical care| other"] to manage their emotional and behavioral needs.


[text name="variable_1" default="Insert Patient Name "] reports their current legal status is: [textarea name="variable_15" default="sample text"]


[text name="variable_1" default="Insert Patient Name "] identifies current employment as [checkbox name="variable_2" value="fulltime | part time| Self employed| Un employed| retired| stay at home| No concerns regarding employment | concerns with employment"] and would benefit from ongoing support via family and sober friends to maintain sobriety to increase employment / opportunity for employment or ongoing engagement in daily activities.


[text name="variable_1" default="Insert Patient Name "] reports their financial concerns are:


[textarea name="variable_1" default="sample text"]. Current insurance provider is: [textarea name="variable_2" default="sample text"] and identifies [select name="variable_1" value="concerns | No concerns"]


[text name="variable_1" default="Insert Patient Name "] current housing situation is: [checkbox name="variable_10" value="recovery housing| return to previous living environment| Living with sober support| ongoing care| other"]

Staff explored with [text name="variable_1" default="Insert Patient Name "] benefits of alternative housing, sober living, recovery housing, treatment with boarding etc. [text name="variable_1" default="Insert Patient Name "] reports no concerns with current reported plan for housing as indicated above

[text name="variable_1" default="Insert Patient Name "] identifies [select name="variable_10" value="concerns | no concerns"] with current transportation.

[text name="variable_1" default="Insert Patient Name "] reports support network includes: [checkbox name="variable_15" value=" family | sober supports| 12 step meetings| Church or other community| Sponsor | Desire to connect with meetings or sponsor | PHP| IOP| OPT| residential| other care"] for ongoing support Staff provided [text name="variable_1" default="Insert Patient Name "] with psychoeducation regarding MAT services.

[text name="variable_1" default="Insert Patient Name "] reports the would like to explore: [checkbox name="variable_19" value="naltrexone | Suboxone| Vivitrol| Sublocade | Antabuse| More psychoeducation| Discussing more with Outpatient services| Follow up with Mat provider outside of RCA| Follow up with psychiatrist | Follow up with PCP| Declined services"]

[text name="variable_1" default="Insert Patient Name "] current mental health dx are:
[text name="variable_1" default="Insert Patient Name "] reccomended ongoing level of care are: [checkbox name="variable_100" value="IOP | PHP | Residential| MAT | Psychiatric support| Family therapy| Mental health therapy| PCP follow up | Substance abuse tx"] and [text name="variable_1" default="Insert Patient Name "] decided on [checkbox name="variable_101" value="IOP | PHP | Residential| MAT | Psychiatric support| Family therapy| Mental health therapy| PCP follow up | Substance abuse tx"]


[text name="variable_1" default="Insert Patient Name "] reports their current PCP provider status is: [select name="variable_109" value= "Has relatioship with provider | Declines having provider"]
[checkbox name="variable_112" value=" They have declined to sign ROI for this provider, psychoeducation was provided regarding benefits of roi and collaboration of care.| Declined to set appointment with staff for follow up, psychoeducation regarding follow up appointment was provided and they have been urged to follow up ASAP| Has roi on file for provider, but declined to schedule with staff. Discussion and psychoeducation of benefits of scheduling has been explored and they are encouraged to follow up asap| Agreeable to setting appointments"]


[text name="variable_1" default="Insert Patient Name "] identifies healthy leisure activities such as:  [textarea name="variable_800" default="sample text"]
has the current diagnosis of:
is reccomended to follow up with to manage their emotional and behavioral needs.


reports their current legal status is:


identifies current employment as and would benefit from ongoing support via family and sober friends to maintain sobriety to increase employment / opportunity for employment or ongoing engagement in daily activities.


reports their financial concerns are:


. Current insurance provider is: and identifies


current housing situation is:

Staff explored with benefits of alternative housing, sober living, recovery housing, treatment with boarding etc. reports no concerns with current reported plan for housing as indicated above

identifies with current transportation.

reports support network includes: for ongoing support Staff provided with psychoeducation regarding MAT services.

reports the would like to explore:

current mental health dx are:
reccomended ongoing level of care are: and decided on


reports their current PCP provider status is:



identifies healthy leisure activities such as:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.34, 32 form elements, 147 boilerplate words, 17 text boxes, 4 text areas, 8 checkboxes, 3 drop downs, 89 total clicks
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