Job Summary: Provides individual and group counseling in assigned program/s as needed. Maintains clinical records and supervises clients in residential and/or outpatient and program activities. Must perform all interactions with clients and staff in a trauma informed manner; abide by HIPAA and 42CFR confidentiality requirements in all interactions with businesses, family members, friends of clients, and other agencies and the general public.
1. Provides individual, group, and family substance abuse and dual diagnosis counseling specific to the primary or secondary needs of the client, as assigned or directed by supervisor. Arrives on time and prepared for groups and individual sessions as indicated by client feedback.
2. Uses standard assessment tools to assess client’s current situation including: medical, employment/support, drug and alcohol use /history, legal, family history, family/social relationships, trauma, depression and anxiety symptoms and psychiatric issues and utilizes information for Treatment Plan.
3. Develop/prepare materials for, and facilitates, educational presentations focusing on substance abuse, women’s issues, and life-skills, as assigned.
4. Prepare and maintain all required treatment records and reports daily to insure all clinical files are current and meet CARF and provider regulations and guidelines.
5. Works with clients to become involved with family education and family therapy. Contacts family members to encourage attendance at family education sessions held two times per week.
6. Responsible for the development and regular update of treatment plans (meeting specific program guidelines) utilizing and documenting client preferences, recording progress notes, preparing discharge summaries, developing aftercare plans, and documenting weekly client staffing reports. Utilizes concurrent documentation 100% of the time as indicated by client signature on Treatment Plan and noted by counselor in progress notes. Complete all required documentation in a timely and professional manner.
7. Responsible for clinical case-management, which includes ongoing contact and coordination with probation, parole, diversion officers, case workers, therapists, family members, and/or any outside source involved with the client, in a manner affecting treatment focus and process.
8. Provides crisis intervention, as necessary, and the ongoing assessment of each client’s stability, functioning, and chemical usage during treatment.
9. Makes appropriate referrals throughout the client’s treatment based on client need. Directs contact with referral source whenever possible. In preparation for discharge, schedules transition sessions one week in advance if client is transitioning to an internal program.
10. Utilizes trauma informed assessments and other tools to develop Treatment Plan and reviews plan with client regularly. May conduct drug and alcohol evaluations using standardized assessment tools to determine client’s current needs and makes recommendations as to appropriate level of care.
11. Participates in clinical team staffing, daily or weekly, as designated per caseload and presents each client case. Documents the staffing decisions and implements the appropriate treatment.
12. Attends and participates in staff training, work teams, and all staff meetings, as directed.
13. Participates in all activities deemed necessary by the Clinical Director and/or Administration to accomplish the above outline duties and responsibilities.
14. Participates in regular supervision meetings with Clinical Director.
15. Provides after hours on-call clinical services on a rotating basis with other clinical staff. Documents all calls, notifies Clinical Director and Counselor of any serious incidents.
16. Provides weekly supervision to provisionally licensed counselors or interns if appropriate and requested.
17. Must be ASI and/or CASI certified and Provider Network approved to do vouchers.
18. Follows necessary requirements as determined by the State in relation to licensure and/or certification.
19. Participates in agency’s quality improvement efforts by collecting and reporting client data to appropriate staff for evaluating program outcomes.
20. Meets with clients to complete standardized drug and alcohol evaluations; completes required paperwork and prepares reports as assigned by Clinical Director.
21. Complete all monthly and Annual Relias online e-learning courses on time, in compliance with state and accrediting organizations training requirements.
22. Attend at least two training sessions per year on cultural competency.
23. Performs other duties as assigned by management.
Qualifications: LMHP or PLMHP required; top preference is dually credentialed LMHP and LADC but will consider single credential; must maintain appropriate and current licensure and training for LADC and LMHP certification; Certified in First Aid and CPR; possess a valid driver’s license; strong organizational, interpersonal, written, and verbal communication skills; ability to perform comfortably in a fast-paced, deadline-oriented work environment; ability to successfully execute many complex tasks simultaneously; and ability to work as a team member, as well as independently. Experience in substance abuse and/or mental health treatment preferred. Must meet the minimum requirements to conduct the Nebraska standardized reporting model for drug and alcohol evaluations.