Job Title: Primary Therapist / Mental Health Counselor

Department: Clinical

Reports to: Clinical Director/Clinical Supervisor

Job Summary:

The Primary Therapist is to provide individual and group therapy sessions for the organization’s clients. The Primary Therapist will help guide and direct client during sessions as well as prepare group notes, support clinical necessity and progress toward treatment plan goals. Maintains open communication lines with facility staff, attending clinicians and physicians, patients and families.

Education and Experience:

• A minimum of 2-years treating substance use and or mental health disorders
• 2+ years utilizing EMR software, KIPU (preferred)
• Experience treating mental health disorders or related work experience (highly desired).
• Required Independent Licensure (State Dependent): LMHC, LCMHC. LPC, LMFT, LCSW, LICSW
• Highly desired, but not required (State Dependent): Addiction's Certifications: MCAP, CAP, CAC, LCADC, CADC, CAC, CAP, LADC, NCAC, MAC, LCAS, CSAC.

Duties/Responsibilities:

• Completes psychosocial intake on clients within appropriate timeframe.
• Conducts Suicide Screening and Assessments.
• Completes the master treatment plan within appropriate timeframe.
• Counsel clients or patients, individually or in group sessions, to assist in overcoming dependencies, adjusting to life, or making change
• Collaborate with other staff members to perform clinical assessments or develop treatment plans.
• De-escalates AMA and other patient problems.
• Documents all activities in the patient medical record and files all notes in the charts on a daily basis for UR purposes.
• Counsel family members to assist them in understanding, dealing with, or supporting clients or patients
• Attends daily staff meetings to enhance communication with clinical staff regarding program and patient issues.
• Participate in required staff training (minimum 20 hours).
• Complete all assigned paperwork in an accurate and timely manner.
• Communicate with other staff as necessary to promote quality patient care.
• Participate in maintaining clean, properly supplied and efficient work areas.
• Observe and report safety, maintenance problems.
• Interact appropriately with patients, showing them respect while maintaining boundaries.
• Maintain professional demeanor at all times.
• Exercise sound professional judgment and seek assistance as necessary to effectively manage patient behavior.
• Protect the privacy of all patient information in accordance with privacy policies, procedures and practices, as required by federal and state law, and in accordance with general principle of professionalism as a health care provider. Failure to comply with policies and procedures on patient privacy may result in disciplinary action up to and including termination of employment.
• May access protected health information (PHI) and other patent information only to the extent that is necessary to complete your job duties. The incumbent may only share such information with those who have a need to know specific patient information you have in your possession to complete their job responsibilities related to treatment, payment or other operations.
• Expected to report, without the threat of retaliation, any concerns regarding policies and procedures on patient privacy and any observed practices in violation of the policy to their supervisor.
• Performs other duties as assigned.

Required Skills/Abilities:

• Knowledge of addictions and mental health complications.
• Familiarity of community healthy resources that support life improvement in physical, emotional, mental and spiritual health, economic security, employment, positive social and family interdependence and positive cultural identity including:
• Experience utilizing DSM-5
• Proficient in Microsoft Office Suite
• Knowledge of referral procedures and admittance criteria for health care and community providers.
• Ability to network and collaborate with healthcare and other social and cultural agencies that can provide services to the patients and families.
• Expertise in problem solving, stress management, ethics and team building.
• Knowledge of alcohol and other drugs that includes:
• Alcohol and addictive drugs and their physical, emotional, intellectual, and spiritual impact on the individual.
• Alcohol and addictive drugs and their impact on the family.
• Ability to determine if a medical emergency exists and to take appropriate action, when necessary.
• Comprehension of emergency procedures used in case of alcohol and/or drug overdose.
• Perceptive of the stages of alcohol and other drug withdrawals and ability to take appropriate action at each stage.
• Knowledge of Federal, State and Municipal laws and/or regulations that regulate the treatment of alcoholism and drug addiction, including: Confidentiality, Patient Rights, Professional Code of Ethics, Discrimination.
• Flexibility to adapt to schedule changes and assumption of responsibilities not delineated in the job description which are related to work as a member of an addiction treatment team
• Staff who assess individuals with substance abuse, dependence, and other addictive behaviors and who plan services for and deliver services to these individuals have the knowledge and skills to do the following:

- Establish rapport, systematically gather data, determine the readiness of the individual for treatment and change, and apply accepted criteria for diagnosis of substance use disorders (If applicable)

- Screen for psychoactive substance toxicity, intoxication, and withdrawal symptoms (If applicable)

- Screen for danger to self or others(If applicable)

- Screen for co-occurring mental health issues (If applicable)

- Analyze and interpret data to determine treatment recommendations and priorities (If applicable)

- With the individual served, formulate mutually agreed-upon, measurable treatment goals and objectives (If applicable)

- Demonstrate adherence to accepted ethical and behavioral standards of conduct (If applicable)

- Participate in continuing professional development (If applicable)

Note: This does not mean that every staff member must have all of these competencies; rather the total complement of staff together possess all of these competencies

New Jersey Required Criteria:

1. Assessing the counseling needs of the clients.
2. Assessing clients using the ASI or other standardized clinical interview tool and diagnosing clients for substance use disorder using the DSM-5;
3. Determining the appropriate level of care according to ASAM Criteria;
4. Obtaining previous records that are relevant to the current treatment episode;
5. Unless clinically contraindicated, collaborating with the client to develop a written treatment plan that includes goals and measurable objectives, and is client centered, recovery oriented;
6. The director of substance abuse counseling shall develop, monitor and provide the client and treatment team a written schedule to update each client treatment plan(s) in order to ensure clients' needs are met;
7. Providing the substance abuse counseling services specified in the client treatment plan;
8. Reviewing clients throughout the treatment episode according to the ASAM Criteria, to determine the need for continued services, transfer, or discharge/transfer;
9. Reviewing and, where necessary, revising the client treatment plan to address ongoing problems;
10. Developing a client discharge/transfer plan to ensure movement to the appropriate levels of care;
11. Contact, case consultation if necessary, and coordination with referral sources, (for example, mental health treatment providers, criminal justice agencies, schools, employers, DCPP);
12. Participating as a member of a multidisciplinary team for assigned clients;
13. Providing active case consultation; and
14. Documenting all counseling and education services, assessments, reassessments, referrals and follow-up in the client's clinical record, and providing appropriate signatures and dating of such entries, including those made in electronic records.

Physical Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk and sit. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl.

Working Conditions and Environment:

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• The noise level in the work environment is usually moderate.
• Position is required to work in indoor and outdoor environments as needed. Potential exposure to aggressive situations.
• Potential exposure to airborne/blood-borne pathogens and other potentially infectious diseases.