Primary Therapist

## Description

**Position Summary:**

The Primary Therapist is responsible for providing mental health or substance abuse treatment services to patients in an inpatient facility setting, providing individual, family and group therapy. Consistently collaborating with all members of the clinical team to formulate proper documentation and assist in coordinating discharge planning.

**Position Responsibilities:**

• Conduct an initial meeting within 48 hours of admission to assess all clients admitted to the facility program.
• Responsible for completing biopsychosocial assessment within 48 hours of admission on all clients admitted to the facility program; Biopsychosocial must contain all required elements.
• Completes all clinical documentation on time and with all required elements.
• Facilitates and/or conducts individual, group and family therapy activities as assigned by the Clinical Director.
• Assesses discharge planning needs upon admission, during the duration of treatment, and the discharge planning process.
• Documents in the medical record any counseling, education, services, individual and group sessions, family interactions, assessments and reassessments, discharge planning, and any other intervention within the prescribed treatment plan assigned by the facility.
• Completes ASAM assessment upon admission, at the time of change in level of care, and upon discharge. Utilizes ASAM assessment to determine appropriate placement within the facility programming (SUD facilities only).
• Completes mental health assessment as needed utilizing evidence-based assessment and standardized tools.
• Completes client evaluations utilizing ASI, DSM-V or other diagnostic, standardized, evidence-based tools.
• Develops initial and comprehensive treatment plan based on interdisciplinary assessments and/or other diagnostic findings.
• Attends daily interdisciplinary or other treatment team meetings to monitor client progress, achievement of treatment planning goals, treatment issues, discharge planning needs, and/or other issues.
• Provides case consultation as needed.
• Involves family in the treatment process on a weekly basis, unless otherwise contraindicate; provides support to the family program as needed.
• Participates in crisis intervention actions as needed.
• Prepares and documents discharge summary within 72 hours of discharge.
• Coordinate care with other providers as needed to obtain collateral information beneficial for the client’s treatment.
• Assists in referrals to 12 step and/or other community programs.
• Demonstrates competence in one or more of the following areas:
• Establishing rapport, systematically gathering assessment data, evaluating readiness for treatment and change, and applying accepted diagnostic criteria for substance use disorders.
• Screening for psychoactive substance toxicity, intoxication, and withdrawal symptoms.
• Screening for co-occurring mental health conditions.
• Supports the organization’s efforts to comply with National Patient Safety Goals related to:
• Infection prevention
• Suicide risk assessment
• Patient identification
• Medication reconciliation
• Performs additional responsibilities as assigned by leadership.

**Workplace Behaviors**

• Demonstrates the ability to complete daily tasks as assigned and meet required deadlines.
• Complies consistently with attendance and punctuality standards.
• Safeguards client rights to privacy and confidentiality at all times.
• Preserves the personal dignity and respect of all clients.
• Maintains a positive, professional, and supportive attitude in the workplace.
• Provides leadership by coaching, supporting, and motivating staff.

## Workplace Responsibility

• Seeks supervision, guidance, or direction when necessary.
• Demonstrates initiative in carrying out assigned responsibilities.
• Actively participates in committees and organizational activities as assigned.

## Adaptability

• Demonstrates the ability to work objectively and maturely under stress.
• Performs in other capacities as needed to support operational needs.
• Responds positively and professionally to changing workplace situations.
• Actively participates in coaching and makes appropriate corrections to work processes.
• Participates in emergency management and response processes as required.

## Professionalism

• Performs duties in a professional manner and consistently conveys a positive image of the mental health profession.
• Works effectively as a collaborative member of the team.
• Complies with organizational dress code and professional appearance standards.

## Ongoing Training & Development

• Attends all required in-service trainings and educational courses.
• Assumes responsibility for individual professional growth.
• Contributes to the professional development of colleagues.

## Communication

• Seeks and responds constructively to feedback and supervision.
• Develops, interprets, and communicates required policies and procedures appropriately.
• Recognizes and takes appropriate action regarding violations of facility policies and procedures, especially those impacting safety.
• Actively participates as a member of assigned organizational teams.
• Participates in facility performance improvement activities.
• Establishes appropriate rapport with coworkers, clients, and visitors.
• Clearly communicates job-related concerns to supervisors and during staff meetings.
• Consistently reports critical information to supervisors, particularly regarding client care, equipment issues, and supply needs.
• Seeks guidance from appropriate leadership when facility-related issues arise.