Treatment plan example ยท Illustrative

Substance Use Treatment Plan Example (Alcohol Use Disorder)

A complete, fictional alcohol use disorder treatment plan: problem statement, long-term goal, measurable objectives, interventions and how progress is measured. Adapt the structure; build the content from your own assessment.

The MentalNote web app drafts treatment plans, intake assessments and progress notes from a recorded session, for you to review and edit. Free plan: 5 web-app scribe sessions a month, no credit card.

Illustrative example only. The client, scores and every other detail on this page are fictional and were written for this page. This is not a diagnosis, a treatment recommendation or clinical supervision. Build every plan from your own assessment of the client, and follow your licensing board, agency, payer and state requirements.

If a client is in crisis in the US, they can call or text 988 (Suicide and Crisis Lifeline). Outside the US, use local emergency services.

Sample alcohol use disorder treatment plan

Each objective names who will do what, how it will be measured and by when. Each intervention says what the clinician will do. That link between problem, goal, objective and intervention is what reviewers look for.

Sample treatment plan (fictional client)

DiagnosisAlcohol use disorder, moderate (ICD-10-CM F10.20), as established by the clinician's diagnostic assessment
Presenting problemAdult client drinks four to six drinks on most evenings and has tried to cut down twice without success. Partner is worried, and the client has been late to work after drinking. No history of withdrawal seizures reported. AUDIT at intake: 21. Client wants to cut down first and decide later about stopping completely.
StrengthsCommitted partner, steady employment, previous periods of lower drinking, open about wanting change.
Problem statementDaily drinking is harming the client's relationship and work and has not responded to attempts to cut down alone.
Long-term goalClient will reduce alcohol use to their chosen target and reduce related harm to relationships and work.
Short-term objectives
  1. Client will record every drink in a daily drinking log for the first four weeks and bring it to each session.
  2. Before making any substantial cut in drinking, client will complete a medical evaluation of withdrawal risk and medication options with their primary care provider within the first two weeks, with consent for the clinician to coordinate.
  3. Client will identify five high-risk situations for drinking and write a coping plan for each by week 4.
  4. After the medical evaluation, client will reduce drinking toward their chosen target (for example, two or fewer drinking days a week, or abstinence) at the pace the medical provider advises, tracked on the drinking log, by the 90-day review.
Interventions
  1. Motivational interviewing to explore ambivalence and support the client's chosen goal.
  2. CBT relapse prevention: functional analysis of drinking, coping and drink-refusal skills, and a written plan for lapses.
  3. Review the drinking log each session and readminister the AUDIT at the 90-day review.
  4. Arrange medical assessment of withdrawal risk before any substantial reduction or stop, because cutting down or stopping heavy, regular drinking can cause dangerous withdrawal; coordinate with the medical provider with written consent.
  5. Offer mutual-help or peer support options the client is open to, and partner involvement with consent.
FrequencyWeekly individual sessions for 12 weeks, then review.
MeasuresAUDIT (10 items, scored 0 to 40); scores of 20 or more suggest likely alcohol dependence and a need for further assessment. A daily drinking log or Timeline Followback interview tracks change between administrations.
ReviewEvery 90 days, or sooner if the clinical picture changes, with client participation. Client and clinician sign the plan.
Discharge criteriaClient meets their drinking target for at least eight weeks, has a written relapse prevention plan, and has links to ongoing support if wanted.

More objectives you can adapt

Replace the numbers and dates with the client's own baseline and targets.

AreaExample objective
Harm reductionClient will not drive after any drinking and will plan transport in advance, by self-report, for the whole plan period.
CravingsClient will use an urge-management skill (urge surfing, delay and distract) and record the outcome for at least three urges a week.
RoutineClient will replace the evening drinking routine with one alternative activity on at least four evenings a week.
RelationshipsClient and partner will attend one joint session to agree on support, if both consent, by week 8.
Recovery supportClient will attend one mutual-help or peer support meeting a week for six weeks, if they choose this option.

Interventions often used

  • Motivational interviewing
  • CBT relapse prevention
  • Contingency management (where available)
  • Mutual-help facilitation
  • Couples or family-involved therapy
  • Coordination with medical care for withdrawal management and medication options

List only interventions you are trained to deliver and the client has agreed to.

Write the progress notes that match

Session notes should refer back to the objectives in the plan. These guides show how:

Other treatment plan examples

See all examples and the blank template on the treatment plan examples hub, or read how to write treatment plan goals and objectives.

Frequently asked questions

Does a substance use treatment plan have to aim for abstinence?

Not always. Many programs support client-chosen goals, including reduced use, while others require abstinence. Write the goal the client and program have agreed and note any medical advice, for example where a condition makes any drinking unsafe.

What are measurable objectives for substance use?

Use counts the client can record: drinking days per week, drinks per drinking day, days abstinent, meetings attended or urges managed. A screening measure such as the AUDIT adds a standardized score at reviews.

Why include a medical referral?

Stopping or sharply cutting down heavy, regular drinking can cause withdrawal that needs medical care, and medical providers can discuss medications that support reduced drinking. A referral, with consent to coordinate, keeps the plan safe.

Can MentalNote draft a treatment plan?

Yes. The MentalNote web app drafts treatment plans, intake assessments and progress notes from a recorded session, and you review and edit every draft. MentalNote is HIPAA-compliant, with a BAA included on every plan. The free plan includes 5 web-app scribe sessions a month.

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