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"]
Substance Use Disorder Service Plan
click to include pt name
Date:
MRN#:
DX:

Referrals for needed adjunct services or Recovery Support Services necessary for this plan








Recovery Planning Team


Community Supports

ASAM Dimensions Service Needs Assessment

Dimension 1.
Dimension 2.
Dimension 3.
Dimension 4.
Dimension 5.
Dimension 6.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.76, 25 form elements, 37 boilerplate words, 5 text boxes, 1 dates, 9 checkboxes, 6 drop downs, 4 conditionals, 32 total clicks
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