Therapist, Outpatient (Sylacauga)

Clinical Responsibilities

• Provides effective clinical assessment of the consumer at intake and continuously thereafter.
• Utilizes assessment data to support a DSM - 5 diagnosis; updates diagnoses as needed.
• Formulates a person centered, recover oriented, medically appropriate treatment plan along with consumer that proves medical necessity and obtains signatures each time the plan is created, updated and/or revised.
• Enters medications into the Pre Entry Medications for Infosribe form upon intake and as needed.
• Provides individual, group, and family therapy, utilizing evidenced based and research based models and theories according to consumer needs as stated in the treatment plan.
• Provides referrals when needed to internal and external agencies.
• Completes intakes for group home consumers and includes needed documentation required for consumers in residential.
• Completes DLA-20 for consumers residing in residential at intake and then at 3 month intervals thereafter.
• Completes DLA-20 for consumers in RDP at admission and then every 6 months thereafter.
• Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation.
• Effectively collaborates with the treatment team members and outside sources in the delivery of clinical services.
• Evaluates the consumer for discharge planning - provides appropriate referrals and/or linkage and closes chart appropriately.
• Completes API reviews and signs off at the end of each time period according to standards.
• Affords assistance in assessing and providing therapy for children and adolescents if needed.
• Effectively demonstrates the application of adult specific competencies.
• Adheres to professional code of ethics.

Supervision and Consultation

• Sets seeks clinical supervision and consultation as needed.
• Accepts and employs suggestions for improvement.
• Actively works to enhance clinical skills.

Clinical Record Keeping

• Documents in a timely fashion per AltaPointe policy.
• Documents appropriate, complete, and clinically comprehensive mental health assessments - including diagnostic impression and referrals.
• Documents measurable and specific problem statements, goals and objectives in the treatment plan.
• Documents in a clear and concise manner treatment goals and objectives addressed, interventions provided, techniques used, consumer progress and response in direct service record.
• Documents case disposition, case closings, follow-up and referrals.