Chemical Dependency Counselor License Exam Treatment Planning and Documentation 3 — Questions and Answers
Question 1: When writing a measurable treatment objective, which component indicates HOW SUCCESS will be observed?
- The target behavior
- The criterion for success (Correct answer)
- The time frame
- The responsible party
Correct answer: The criterion for success
The criterion specifies the standard (e.g., 'with no more than two missed sessions') that will be used to evaluate whether the objective was met.
Question 2: A counselor notices a client's treatment plan has not been reviewed in 90 days despite agency policy requiring 30-day reviews. The counselor should:
- Backdate a review to avoid audit issues
- Conduct an immediate review and document the lapse per agency protocol (Correct answer)
- Wait until the next scheduled session to address it
- Ask the supervisor to sign off on the old plan
Correct answer: Conduct an immediate review and document the lapse per agency protocol
Conducting and documenting an overdue review corrects the deficiency; backdating is fraudulent and violates ethical and legal standards.
Question 3: Which of the following is an example of a SMART treatment objective?
- Client will improve coping skills
- Client will attend three AA meetings per week for 30 days as verified by signed attendance slips (Correct answer)
- Client will feel better about themselves
- Client will stop using drugs
Correct answer: Client will attend three AA meetings per week for 30 days as verified by signed attendance slips
A SMART objective is Specific, Measurable, Achievable, Relevant, and Time-bound — the AA meeting example meets all five criteria.
Question 4: In the context of co-occurring disorders, integrated treatment planning means:
- Treating substance use and mental health disorders in separate plans by separate providers
- Addressing substance use and mental health needs within a single, coordinated treatment plan (Correct answer)
- Combining medication and counseling in the same session
- Using the same evidence-based curriculum for all clients
Correct answer: Addressing substance use and mental health needs within a single, coordinated treatment plan
Integrated treatment for co-occurring disorders combines both conditions into one unified plan to address their interaction and avoid conflicting interventions.
Question 5: A client signs a release of information authorizing the counselor to contact their probation officer. This release:
- Allows disclosure of all information in the clinical record
- Limits disclosure to information specified in the release and required by 42 CFR Part 2 (Correct answer)
- Grants the probation officer full access to attend sessions
- Automatically renews every 90 days
Correct answer: Limits disclosure to information specified in the release and required by 42 CFR Part 2
Under 42 CFR Part 2, releases must specify what information can be shared; counselors cannot disclose beyond the scope stated in the signed authorization.
Question 6: Which documentation element is most important for demonstrating medical necessity for substance use treatment to an insurance payer?
- The client's preferred treatment modality
- Clinical findings linking assessed severity to the level of care requested (Correct answer)
- The counselor's years of experience
- The agency's accreditation status
Correct answer: Clinical findings linking assessed severity to the level of care requested
Medical necessity is established through clinical evidence showing the client's condition requires the specific level and type of treatment being authorized.
Question 7: Progress notes in substance use treatment should be written:
- Only when significant events occur
- After every client contact, documenting content, client response, and progress toward goals (Correct answer)
- Monthly during scheduled treatment plan reviews
- By the supervisor based on counselor verbal reports
Correct answer: After every client contact, documenting content, client response, and progress toward goals
Best practice and most regulatory standards require a progress note for each client contact to maintain a continuous, auditable clinical record.
