Primary Therapist

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.
• Reports all incidents promptly and completes accurate incident documentation.

Safety, Risk Management, Infection Control & Regulatory Compliance

• Reports any personal symptoms of suspected illness or contagious disease to a supervisor in a timely manner.
• Consistently utilizes proper hand hygiene and infection prevention techniques.
• Reports all incidents and near-misses in accordance with organizational policies and procedures.
• Adheres to all facility policies, procedures, and safety protocols.
• Maintains a safe, clean, and secure physical environment at all times.
• Ensures appropriate protection of client confidentiality in accordance with HIPAA and organizational standards.
• Complies with all Joint Commission Standards applicable to the role.
• Complies with all State Licensing and Regulatory Guidelines .
• Actively participates in Performance Improvement (PI) and Quality Assurance (QA) activities.

Substance Abuse Competency

• Staff who assess, plan services for, and provide care to individuals with substance use disorders demonstrate the knowledge and skills to:
• Establish rapport, systematically gather data, assess readiness for treatment and change, and apply accepted diagnostic criteria for substance use disorders.
• Screen for psychoactive substance toxicity, intoxication, and withdrawal symptoms.
• Screen for danger to self or others.
• Screen for co-occurring mental health conditions.
• Analyze and interpret assessment data to determine treatment recommendations and clinical priorities.
• Collaborate with the individual served to formulate mutually agreed-upon, measurable treatment goals and objectives.
• Demonstrate adherence to accepted ethical, professional, and behavioral standards of conduct.
• Participate in continuing professional development and ongoing competency training.

Mental Health Competency

• Staff who assess, plan services for, and deliver care to individuals with mental health conditions demonstrate the knowledge and skills to:
• Establish rapport, systematically gather data, assess readiness for treatment and change, and apply accepted diagnostic criteria for mental disorders.
• Screen for common symptoms of mental illness and psychiatric instability.
• Demonstrate working knowledge of general DSM terminology and diagnostic language .
• Demonstrate understanding of common mental health risk factors .
• Screen for suicidality, self-harm, and other high-risk behaviors .
• Analyze and interpret assessment data to determine treatment recommendations and clinical priorities.
• Collaborate with the individual served to develop mutually agreed-upon, measurable treatment goals and objectives.
• Demonstrate adherence to accepted ethical, clinical, and professional standards of conduct.
• Participate in ongoing continuing education and professional development activities.

Licensures and/or Certifications

LPC, LMFT, LMHC, LCSW (preferred); RCSWI, RMHCI or other mental health or substance abuse license or certification.

CPR certification required.

Education and Experience:

Graduate from an accredited college or university with a minimum of master's degree in psychology, Social Work, Counseling and/or mental health-related field.


Requirements:


TECHNOLOGY


General knowledge of:


Excel, WORD, and Power Point, KIPU, Email, Tablet, and general desktop applications.


EQUIPMENT


Computer, calculator, Fax Machine, copy machine, telephone system, ID camera, cell phone.


VEHICLE OPERATIONS


Valid driver's license


AGE SPECIFIC CONSIDERATIONS


Adults 18 years or above


ENVIRONMENTAL CONDITIONS


Controlled environment temperature with 80%-90% of the time spent indoors.


JOB CATEGORY STANDARD PRECAUTIONS


Universal precautions


PERSONAL PROTECTIVE EQUIPMENT


None


POTENTIAL WORKPLACE HAZARDS


Normal Workplace Hazards


POTENTIAL WORKPLACE VIOLENCE


Low/Medium


SPECIAL CERTIFICATIONS


CPR Certification (if applicable)

PHYSICAL DEMANDS


Physical Tasks


0-25%


26-50%


51-75%


76-100%


Standing

X

Walking

X

Bending


X

Crouching


X

Carrying


X

Pushing


X

Pulling


X

Sitting

X

Reaching


X

Reading

X


Driving


X

LIFTING/LOWERING


Light (1-20 lbs)

X

Medium (21-50 lbs)

X

Heavy (51+ lbs)


X