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[Music].this episode was pre-recorded as part of.a live continuing education webinar on.demand CEUs are still available for this.presentation through all CEUs register.at all CEUs comm slash counselor toolbox.I'd like to welcome everybody to today's.presentation on assessment and placement.patient placement tools the ACM FAR's.and the locust over the course in the.next hour we're going to differentiate.between level of care guidelines and.patient placement criteria which are two.things that you use especially if you.are involved with insurance billing.we'll learn about the functional.assessment rating scale which is.required in some states we'll learn.about the ACM which is required by most.insurers but not all of them some use.the locus instead so we're also going to.learn about that and we'll discuss why.these tools are used and how they can.benefit the clinician and the clients.patient placement criteria suggest a.treatment intensity level that meets the.needs of the client so the a sam is.actually the AC MPP c1 and to patient.placement criteria the locus has also.has guidelines for what level of care.the person should generally be at now.the patient patient placement criteria.I'm going to try not to say that too.many more times tells you for example.the person probably would benefit from.being in intensive residential or.partial hospitalization but it doesn't.specify to any great degree what.services would be provided in that level.of care that's usually governed by the.insurance companies and/or the state in.which the person resides and you live.the level of care guidelines are defined.by insurance providers and the state in.some cases and these are the guidelines.that if you google like Blue Cross and.Blue Shield level of care guidelines.residential or intensive outpatient you.will come up with this list of things.that B CBS says has to be there in order.to qualify for what they call IOP.services and the criteria differ a.little bit between each insurance.company so if you're working with.multiple insurers you want to make sure.that you create a situation in which.you're meeting the most stringent.requirements of all places like how.quickly does someone need to see a.psychiatrist how quickly does someone.need to have their treatment plan.completed so why do we use these it.provides a biopsychosocial approach to.care management which is really.important because biopsychosocial is not.only kind of the wave of the future but.it also takes into account a lot more.than just how the person's thinking or.you know what might be going on mood.wise with them we want to look at what.is their environment what medical.conditions might be contributing to or.exacerbating their mood conditions it.assists in defining potential strengths.and obstacles to the recovery process as.the client sees them and.when I talk about these things now the.ACM is typically used for addictions.it's put out by the American Society of.addiction medicine always got to.remember what acronyms stand for however.ACM also recognizes that co-occurring.disorders addiction and mental health.are the expectation not the exception.so they've expanded their criteria to.include mental health but either either.one can really be applied to mental.health diagnosis and/or addiction they.help guide treatment planning for.biomedical issues because it brings it.to the forefront and says dude does the.person have any biomedical issues that.might be causing a problem I mean if.they've got hepatitis or if they've got.chronic pain that might be exacerbating.their mood issues go figure.so we want to make sure that we're.paying attention to all the things that.might be disrupting their sleep and.causing depression or anxiety or you.know interpersonal problems obviously.they all look at cognitive emotional and.behavioral issues that's generally what.people come to us for so we would want.to look at that they consider.motivational issues how ready is the.person to change you may see even in.mental health situations clients who are.involuntary or less than voluntary maybe.their attorney said they had to go get.counseling or their spouse told them you.need to go get this taken care of.because I'm tired of it those are not.the people that are coming going I got a.problem and I'm ready to do whatever it.takes to get better so we want to look.at where their motivation is because.then we can create a treatment plan that.uses motivational techniques to help the.person move towards the goals that are.important to them and also create goals.that you know by default are also what.you know the referring person wanted.them to get out of it we'll talk about.that a little more later and the.recovery environment if you take a.person who is trying to recover from.depression or anxiety and.they are living in an environment that.is unstable that is just replete with.people who are angry and stressed out.and there's a lot of chaos how is that.going to affect them versus if they are.in a stable living environment that I.mean every environment has its stressors.but one that is more stable and.supportive and all that happy stuff I.think we can see pretty obviously that.recovery environment does play a huge.role and when I talk with my clients.about recovery environment we talk about.not only where they live but also where.they work because they spend 40 plus.hours a week generally at this place.that they work so that is part of their.recovery environment if that place is.chaotic and stressful and just miserable.to be in I mean they may not be able to.leave it but we need to pay attention to.that and help them figure out how to.deal with those stressors or buffer.against those stressors so it doesn't.keep them from making progress and these.tools can also assist us in providing.specific measurable achievable realistic.and time limited goals SMART goals.because it helps us break it down.instead of just treating depression.which is kind of this big global meta.concept thing or identifying okay you.want to address the biomedical condition.of your diabetes you want to address.your recovery environment specifically.as it relates to getting along with your.co-workers so it helps us narrow down or.specify different treatment goals that.the person may need to work toward in.order to achieve their over overarching.goal of recovery happiness however you.define it however they define it so.we're going to start with the far I love.the FAR's a lot of people have never.heard about the FAR's which is why I put.it out here even if your state doesn't.require it it might be worth looking.into in terms of having it as a tool to.use with your clients and to help them.use to create more specific goals and.objectives is put out by the or.was initially created at the University.of South Florida in Tampa and you can.get your Fajr certification online for.free if you want to get certified in it.you can also download the manual which.is a link to it is included in your.classroom if you like the FAR's and you.want to use it as sort of a ancillary.tool it's not a placement guide per se.it helps you identify which problems are.the worst and specifically why they're.being rated that way and if you'll.understand more when we look at it and.it helps more clearly define anchors for.behavioral observations I found that.when we started using it at the clinic I.worked at in Florida the clients.actually were a lot more excited because.they could see notable changes from.treatment plan assessment to treatment.plan assessment which we did every.thirty days and they could see their.numbers going down which is good you.want to go down more towards one where.it's not much of a problem or zero no.problem at all so the FAR's has multiple.things that it assesses and it's ranked.on a nine-point Likert scale which can.be a little overwhelming at times they.do give you word anchors here so you can.use those so for depression for example.if a client comes in with depression we.may just normally say alright there.they're presenting with the press of.issues they meet the DSM criteria and be.done with it.this actually says what things are going.on with this client that we are using to.define the depression or that might.indicate that there's depression going.on so we can mark off those and.obviously the more things you Mark the.more weight it might give to that.problem now for example under depression.it has anti depression meds obviously if.you mark that and they are relatively.stable on their antidepressants that's.wonderful depression may be a less less.than slight problem.even though it has.they marked so it gives you an idea.about where you're standing.anxiety obviously again it has.anti-anxiety meds now that can be a.cause for concern for some of our.clients maybe they don't want to be on.those meds anymore it's also important.to understand whether the meds are.working if they're presenting with.symptoms of depression or anxiety that.are in your moderate range or above for.example and they're on medication for.anxiety or depression already then we.want to talk to them about how much.improvement of you seen since you.started taking this medication and.advocate for them as needed maybe to go.back to their physician or psychiatrist.and talk about the treatment plan or.what may be going on if that meds.working for them maybe it needs to be.increased maybe they need to switch all.again altogether to a different type of.antidepressant or anti-anxiety hyper.effect thought processes cognitive.performance medical and physical now.you're going to go through and you're.going to mark each one of these if the.client is having problems for example.with cognitive performance and you have.a short attention span that can be a.treatment goal in and of itself.cognitive performance is pretty broad.but if we can define it as something.small and maybe it is when client.presents it's a severe problem it's a.seven and it treatment reassessment.we've moved it down to a five or a six.the client can see on that one.particular problem they've made progress.most of our clients present with.multiple problems multiple issues.multiple presenting symptoms and if they.can see progress in one then they can.see that they're making progress even if.they're not feeling a ton better they.can see that they're making baby steps.and that often is motivating for a lot.of our clients and it can help when.you're sending things back and trying to.get additional services or additional.days authorized from the insurance.provider if you can show what your.monitoring other things the FAR's.measures and I'm not going to distribute.each one of these in super detail.traumatic stress substance use.interpersonal relationships you may have.somebody who has four different.treatment plan problems just under.interpersonal relationships and that's.fine you can choose a place to start.addressing or ask the client what is the.most important thing for you or what do.you think would be most helpful for you.to get you started moving toward where.you want to be and maybe it's their.traumatic stress maybe it's their.relationships that's going to be kind of.up to the client what they're most.motivated to work on if they have if.you've identified 15 different things on.the FAR's it's going to be overwhelming.to hand them a treatment plan and say.okay we need to work on all this they're.gonna be like what that would be like.starting college and then giving you.your entire curriculum and say okay.we're going to start working on all of.these classes right now you would have.looked at the advisor like they had.three heads so we want to help them.narrow it down and learn how to.prioritize which things they're most.motivated to work on and they think are.going to be most helpful in moving them.in the right direction because as they.experience positive changes they're.presenting symptoms or presenting issue.will probably show some positive effects.which will keep them moving forward.family environment and relationships are.different because you know again the.environment your recovery environment is.different than your relationships.necessarily socio legal issues when.we're looking at conduct disorder when.we're looking at people who might have.substance abuse issues and you know duis.things like that that becomes a.treatment plan issue potentially maybe.they're working towards going to court.for the getting off probation for their.DUI or something it's important to know.what what some of their motivators are a.lot of times socio legal.can be used as a motivating factor is.also as a treatment plan problem if.they've got pending charges doing well.in treatment generally looks good to the.court for example if they're on.probation the same thing it's a you can.use it as an advocacy sort of thing work.school problems some people have some.basic issues and problems with what I.consider activities of daily living so.we want to help them look at work.attendance and how long they stay.employed and how they get along with.others and you know presentation at the.office if they've been fired a bunch of.times let's take a look at that was it.an interpersonal issue or was it some.sort of skill set that they didn't have.and activities of daily living.functioning you may or may not in your.particular setting handle this a lot of.people consider this more case.management however banking back to.Maslow's hierarchy if they don't have.enough money to buy food and keep a roof.over their head they don't have a safe.place to live and they can't afford.medications or medical care they're.going to have a hard time dealing with.any sort of depression self-esteem or.relationship issues so however you.consider it if there are ADL issues you.may need to refer out if that's not.something you treat at your facility the.ability to care for their self most of.the time this is going to be a non-issue.for a lot of our clients that we see in.outpatient every once in a while it does.become an issue I've worked with some.clients who are schizophrenic and they.are on the fact team which stands for I.don't remember what it stands for.but it's an intensive case management.program where the case managers and or.counselors go around and they touch base.with people in their residence in their.home to make sure the person is taking.their meds and showering and doing what.they need to do it assesses danger to.self and others you know you're going to.do that on any good assessment anyway.and identifies any security management.needs.so this the FAR's is really.comprehensive at helping you identify.any of those minutiae problems in.addition to the big problems that may.need to be addressed or considered when.doing your case conceptualization what.is it that's contributing to this.person's current mental health state so.the FAR's is optional in many states.it's required for example at least when.I left Florida it was required by any.state that received funding from from.the state by any treatment center that.received funding from the state so if.you're not familiar with it take a look.at it if you like it great if not you.know there are other tools out there.that may be more useful or you may.already have an assessment tool that you.love and that's awesome the ACM.is patient placement criteria we.generally in the treatment centers that.I've been in the insurance companies and.the organizations required the ACM to be.done add assessment reassessment and.discharge so pretty much every 30 days.the ACM assessed your physical dimension.it asks about acute intoxication.withdrawal potential now remember this.originated as a patient placement.criteria for clients with substance.abuse issues so that that one is still.on there.your client even if they are not an.alcoholic or a drug addict may be using.alcohol excessively right now to deal.with their depression their grief.whatever's going on so if that's an.issue and you think it is an issue of.concern you can mark that off bio.medical conditions what other things are.going on that may or may not be stable.that may or may not be contributing to.this current situation and that can be.anything from chronic pain to hepatitis.to HIV to you know you name it so.talking about the client about what.medical conditions do you have going on.it becomes more important if you're.going to try to place somebody in.residential but.it's you know less important in IOP or.outpatient services because we're going.to refer out to a to a physician we.don't have to figure out whether we can.manage it on site then it goes on to ask.about emotional and cognitive issues.what emotional or behavioral issues are.present and how serious are they have.treatment resistant or accepting are.they so if they've got major depressive.disorder maybe they have some suicidal.ideation and they are ready for change.they are there they are wanting to help.help they're wanting treatment that's.far different than someone who is.brought in on a Baker Act brought in.involuntarily who is not wanting to.change they are still in that state.where they are wanting to harm.themselves or someone else so that will.help you kind of gauge what level of.care that person may be best at.obviously if they're actively suicidal.or homicidal it's sort of a no-brainer.about the level of care you're not going.to put them in once a week outpatient.but this helps you you know really.demonstrate because as they always say.if it's not written down in the chart it.didn't happen you can demonstrate that.you went through in a systematic way not.only to identify the issues that needed.to be addressed for treatment planning.but you identified any issues that might.make the treatment placement more.important where someone needs a higher.level of care to maintain their safety.behavioral looking at relapse or.continued use potential continued use.obviously we're talking about substances.but behaviorally we also want to look at.your mental health issues if someone was.self harming if they were cutting if.they were engaging in binging and.purging behavior if they were doing some.using some sort of compensatory.behavioral thing in order to deal with.depression or anxiety or grief or anger.that's going to be important for us to.identify how safe is it basically.is what the ACM is getting at to have.somebody in once a week do they meet.once a week care or do they really need.to touch base more often in order to.maintain any gains that they've gotten.from higher levels of care and the.social and environmental aspect what is.their recovery environment like do they.have social support is it a safe stable.environment where the same people live.there and they relatively they get along.with them relatively well or is it a.chaotic violent destructive environment.may or may not be able to change that.but we can identify whether you know if.it's not a supportive environment we may.recommend a higher level of care and.they score out for a higher level of.care by the same token if they choose.not to maybe they score out for.residential on the a Sam you know you go.through and do all your checkmarks and.it says yep the best placement would be.residential for you but this person says.now can't do residential or I won't do.residential and they have an option.which generally they do then we want to.understand that recovery environment.might be a primary priority in treatment.planning so how can we help this person.make mental health and/or substance.abuse related gains you know start.getting better in an environment that's.not 100% conducive so you're a cm levels.are really pretty simple.early intervention which is basically.getting to people before there's a big.problem you know before it becomes an.addiction before they become clinically.depressed and relaxed prevention so it's.at the beginning at the end when they.trying to prevent them from ever having.to use services giving them the tools.that they need and at the end helping.them maintain their gains probably once.a week group this is really high level.if you will or services or you're not.going in depth with the person it's.mainly psycho ed.and community building outpatient is.less than nine hours a week and that's.what most of you probably are involved.in you're probably in private practice.or working on an outpatient basis where.you're seeing clients once a week maybe.three times a week for group it's less.than nine hours per week so that's a.pretty broad range of what you can.qualify for outpatient generally.insurance is not going to pay for nine.hours of individual a week so you know.there's some question about how to build.for services but it does not meet the.standard of intensive outpatient until.it becomes nine or more hours a week.partial hospitalization this is.basically people who don't want to be in.residential but they need somewhere safe.to be the majority of the time but.they're not at work so oftentimes it's.like after work from 6:00 until 10:00.five days a week at 20:00 hours and.maybe optional Saturday and Sunday.services not services but Saturday and.Sunday groups to help them when there's.downtime people in PHP need a whole lot.of structure in order not to start.decompensating residential pretty.self-explanatory they're going to be.staying there 24 hours a day seven days.a week.level four is medically managed.inpatient services and these are the.people who need to be in a psychiatric.hospital they need to be somewhere where.physicians are on duty all of the time.because of medical conditions.psychiatric conditions that may require.that level of intensity so the ACM is.what's used at a lot for a lot of.facilities especially ones that provide.substance abuse services and I think.partly and I'm guessing here purely.speculation from using all of these.instruments the ACM is really quick to.do once you get used to it you can do it.in under five minutes figure out where.somebody scores and be done with it the.locus on the other hand.measures a lot of the same things but it.is a much longer instrument to use so.some agencies may may not want to use it.certain insurance companies require the.locusts to be used so okay so what does.the locusts measure very similar to the.ACM the risk of harm how what is the.risk that they are going to harm.themselves if they are in a outpatient.situation minimal so that would probably.be outpatient low again outpatient once.you get higher you're probably going to.move towards if they have a high risk of.harming themselves you want them to be.in residential their functional status.and on the locusts you can go through it.you can download it in your class they.give you definitions for what each one.of these represents so they are anchored.so you know what minimal impairment is.defined as but I didn't figure you'd be.interested in going through the minutiae.today somebody with minimal mild.moderate serious or severe impairment.you can see that the lower the score the.lower the intensity of services they're.probably going to be put in so we've.looked at risk of harm and functional.status then it goes to medical addictive.and psychiatric comorbidity which is a.little bit different than the a Sam.which separates biomedical from.cognitive and behavioral but you know.we're still looking at kind of the same.thing when they talk about comorbidity.they're saying you have your presenting.issue whatever that is.depression anxiety addiction what other.things are going on so do you also have.medical conditions that are comorbid to.the primary presenting issue a lot of.people will have some level of.comorbidity however it may not be severe.you may not have severe medical issues.and severe psychiatric issues it could.be some minor chronic pain that's being.managed pretty well and your presenting.issue which is maybe major depressive.disorder.so you're getting an idea about whether.there's anything else that we need to be.attending to recovery environment assess.on both a Sam and Locust your level of.stress and your level of support I do.like how the locust breaks this out how.stressful is the environment remember I.said I talked to my clients about home.versus work because both of those are.their recovery environment it just.happens to be which time of day so what.is the level of stress and what is the.level of support in each environment.maybe they have an extremely chaotic.stressful work environment with our home.environment is super supportive so with.their level of support at home even.though they've got a fair amount of.stress in part of their recovery.environment they may be able to manage.and our treatment and recovery history.when they've gone to treatment before.assuming they have what happened did.they respond well well great then we.know that we probably can tune up some.skills that they had before they already.know what works for them that's awesome.if they've had moderate or an equivocal.response so you're looking at it going.not sure if it helped very much that's.going to be more of a problematic.because we don't know what's going to.work for this person we have an idea.that what they did before didn't work.super well or there was something that.prevented it from working well sometimes.motivation levels or the way it's.presented can prevent prevent them from.benefiting from treatment as much or.maybe something just completely.different that was going on maybe they.had somebody in her family died and they.weren't focused on treatment at that.point but we want to look at what their.history has been if they've had a.negligible or poor response then we may.need to look at a higher level of care.now one of the rationales for this is.that if you move them into higher levels.of care then your extra cating them if.you will from some of the stress.SURS that may have distracted them and.kept them from being as engaged or.treatment from being as effective as it.could have been this may or may not fit.with your clients history so you want to.look at really consider this what went.on that may have prevented the person.from getting maximum benefit from that.treatment program it may have just been.a poor fit and so that's something that.we want to consider and not say well you.need a higher level of care if the prior.level of care maybe act adequate and.accurate but the last program was not a.good fit for that client engagement.number one is optional optional optimal.the client is there they're ready to go.in substance abuse recovery and even.some mental health recovery we're.starting to look at the stages of change.more this would be the action stage the.client is there they're like I'm done.with this I'm sick and tired of being.sick and tired help me figure out what.to do.level 2 the person is preparing and.determined to do something about it in.the very near future they may just be.dipping their toe in the water not quite.ready to commit yet level 3 4 & 5 the.person's really not engaged in the.treatment process now if somebody is not.engaged in the treatment process it may.or may not benefit them to be in a.higher level of care but you'll see in a.few minutes the locus dimensions will.push them more towards a higher level of.care for their own safety or two.hopefully maximize treatment gains so.how do we use all this information you.rank them on all these sub scales you'd.give them between a 1 and a 5 what do.you do so level 1 is basically your.prevention your early intervention up to.3 hours a week now remember there was a.much different definition with.with the ACM but for locusts is up to.three hours a week the risk of harm is a.two or less so they're pretty much.pretty much no risk of harm they're a.good level on their functional status.again a - or or less comorbidity is it -.or or less so they don't have a lot of.compounding issues in their recovery.environment their treatment and recovery.history they've always done pretty well.when they've tried and some clients.don't have any history so you might not.have anything to put here.their engagement they're highly engaged.they're ready to do something so these.clients are probably going to benefit.from your lower intensity services if.you will their level to which which is.your low intensity IOP is more than.three hours a week the risk of harm is.still a two or or less because they're.living in the community their functional.status they need to maintain a 3 or less.they need to be relatively independently.functional on their own but there can be.a little bit more impairment we still.are looking for low comorbidity and a.supportive low stress recovery.environment positive recovery history.and an engagement we want them to be.optimally engaged we want them to be.ready to go for Li o P again these are.people who are not going to be seeing.you more than a few hours a week so they.need me to be able to maintain gains and.not be compensate without seeing you.every single day or multiple days.multiple hours multiple days a week.level three on the locus usually equates.more to IOP and PHP anywhere from nine.hours to 20 hours a week these people.have a higher risk of harm but it's.still not one where you'd be concerned.as a clinician that the person needs to.be in in an inpatient setting their.functional status is still really good.they're able to for the most part do.what they need to do to function their.quality of life.may not be optimal if it was they.probably wouldn't be seeing us however.they're able to feed themselves bathe.you know do the basic things comorbidity.is still pretty low for IOP and PHP we.want to make sure that they are not.going to suddenly decompensate medically.if they've got a medical issue or an.addiction issue going on that's not.their primary presenting issue the.comorbid issues are relatively under.control and not causing a significant.impact on the primary presenting issue.their recovery environment can be a.little bit more chaotic but we still.want it to be relatively supportive and.not overly stressful if it's overly.stressful they're probably not going to.be able to focus on treatment and do the.things they need to do which will lead.to low compliance and potentially low.benefit potentially some clients will.not go to a higher level of care even if.their recovery environment is not super.supportive so we just need to have that.out there and know how we can work with.it and their engagement can be a little.bit less for IOP and PHP if they're just.not like all over it and super enthused.about doing what needs to be done and.doing their homework assignments and all.that kind of stuff you know that's okay.because you're going to see them more.often so you can provide more prompts my.son is in high school right now and I.kind of think of it this way as you know.I see him every day so I can prompt him.to do his homework do his assignments.make it get his stuff done if I need to.and you know follow up and do that sort.of thing because he's got all that.engaged in some of the stuff he's.studying right now you know I'm just it.is what it is I'm a realist hopefully.when he gets to college and he only sees.his teachers you know once maybe three.times a week he's going to have more.enthusiasm and will be more self.motivated so he won't need somebody kind.of looming over him.levels four through six on your locus.correspond to residential I didn't see a.need to go through those in high level.minutiae but you can get an idea how.those the ACM and the locust are really.looking at similar things they break.them down a little bit differently and.they identify a need for a higher.intensity level of care more connection.with the clinician based on how bad how.severe the problems are how unstable the.environment is and how low the.motivation is which you know like I said.there are some reasons for that may not.always play out the way you had hoped.I worked my first job out of college was.working with felony probation and parole.and those clients were really not.motivated to be there there's just there.really I can't think of a single one of.them who was excited to go to group.would they have been better off you know.we had them in outpatient care because.they were not willing and even if we.would have put him in residential they.probably wouldn't have done the work.they would have done what they had to do.to get by and probably not internalized.it because they weren't motivated to.learn they weren't motivated to work on.that issue at that point one of the.other nice things about these guidelines.no matter which one you use the locus or.the ACM when you look at motivation.levels if they have low motivation then.it probably points you in the direction.of brushing up on those motivational.interviewing skills and the motivational.enhancement approaches to figure out how.to create win-win situations a lot of.times that puts the client more in.control where you're saying what is it.that you want to work on when I work.with substance abuse clients if they're.not ready to give up the substance they.don't think they need to get up the.substance but they're on probation for.example I'm like okay you know you're.not ready to do that you're stuck with.me for the next 12 weeks.or however long it is you should usually.it was a 12-week session and you don't.want to go back to jail.I don't want you to go back to jail but.in order to stay out of jail you can't.use so how can I help you not use and.comply with the requirements of your.probation or whatever your employees.that employer says or whatever it is how.can I help you meet your goals which are.to get off probation and not have to see.me again and generally the way to do.that was to comply with my goals and it.was staying clean for that period of.time so I wasn't telling them from the.get-go you can't ever use again I was.telling them I hear what you're saying.let's see what we can do.during this 12 weeks one of the other.things I would often tell them is I am.state-sponsored therapy you know the.court is paying for you to see me you.might as well get benefit out of it so.what can we work on together that you.might benefit from sometimes that would.alter the conversation a little bit.where they didn't feel like I was trying.to judge them because they used cocaine.or put them into a group with everyone.else you know I was really talking to.them about how is it that I can be of.service to you so the 5ms these are what.we need to do at every level regardless.of is early intervention services.intensive outpatient residential we need.to motivate clients look at their.readiness for change and the recovery.environment engage them and build.alliances by creating win wins we want.to model this because as we model it.they will learn from it if we ask them.instead of saying okay your treatment.plan goals are X Y & Z if we ask them.what do you think would help you meet.the requirements that you've got or you.want to be happier you've lived in your.skin for 40 years I've known you for 40.minutes so you're the expert on you why.don't you tell me what the first thing.is you think would be helpful to work on.to start moving you.forward stepping down we are always.probably going to be seen by most.clients as an expert there's always.going to be a power dynamic but we can.minimize that some by being somewhat.realistic and saying you know you better.than I know you.help them feel comfortable speaking up.and saying that's not going to work for.me.and then figure out how to make it a.win-win if they score on the ACM of the.locus for residential and they say I'm.not doing that.for cultural reasons because I am a.single parent and I've got two kids at.home because I can't lose my job there's.a whole host of reasons they might not.be able to or be willing to do.residential even though it would.probably be the best placement I want.them to feel comfortable telling me that.instead of just walking out and never.coming back so we can talk about okay.well what can you do and then how can we.fill in the gaps to minimize or mitigate.those things that might cause harm to.your recovery we need to manage and it's.just to make it an M family significant.others work school legal and financial.we need to help them figure out how to.balance all these things figure out how.to bring in a healthy support network.which may or may not be blood relatives.that's going to be partly culturally.defined and partly defined by the client.themselves help them figure out how to.make work you know that's part of their.recovery environment we need to help.them figure out how to make that not.harmful to them preferably helpful and.inspiring and all that kind of stuff but.at least not harmful how can I deal with.their legal issues I don't want them go.into prison after they've gone through.you know eight weeks of treatment with.me and financial issues obviously we're.not financial counsellors we're not CPAs.we're going to refer out for some of.this stuff but it's important to make.sure that we're making the referrals so.the clients can get that lower level of.Maslow's hierarchy all in order.medication is needed for detox for HIV.AIDS for medication-assisted addiction.treatment and I separate that from.psychotropic medication because most.people don't lump them together.medication addiction treatment is more.like your methadone and your suboxone.psychotropic medication also assists.treatment if they're on an SSRI or an.SSRI.there's one of those other mental health.medications that's working for them but.we need to advocate for them advocate.help them advocate for themselves their.meds aren't working or if there are side.effects that they're finding troublesome.we also need to help them make sure that.they can pay for their medication and if.they can't again you may refer to a case.manager but do know you can go to a.pharmaceutical company's website find.the patient Assistance Program page and.most insurance companies have patient.assisted programs for most medications.that are out there it so in most cases.it's like a half a page or one page.sheet the doc sells out faxes in and the.client can get low-cost medication that.may not be on other formularies they.need to go to meetings some sort of.integration with other people.mental health or otherwise if they're in.if they're seeing you for Greece there.are grief support groups there's.depression not depression just divorce.support groups there is our support.groups for survivors of suicide so when.I talk about meetings I'm not just.talking about addiction I am talking.about helping people connect with other.people that are going through similar.things and you know succeeding at moving.towards the moving towards recovery and.we need to monitor the continuity of.care we want to make sure that relapse.prevention activities are in there if.they're seeing you for depression and.you see that they're starting to.decompensate or they're starting to do.things that you know is trigger their.depression in the past or you're coming.up on an anniversary of a significant.loss which may trigger their depression.you know this is what we want to monitor.for and point it out to them so they can.learn to self monitor and we're also.encouraging them by us monitoring what.they tell us about the recovery.environment and social supports we're.encouraging them to be more aware and.you could put mindfulness here but that.would just be another M we want them to.learn how to do all of these things for.themselves so they can advocate.they can self-motivate they know where.they can go to find other people who are.supportive so the FAR's is a very.helpful tool to conceptualize problems.and rank severity and kind of create sub.goals for treatment plans it provides.small focus areas that we can use and.that clients can hone in on so if.they're working on instead of just.relationship skills they can work on.specific aspects of that and see that.aspect improve which is obviously going.to improve the meta concept to the ACM.and locusts are used relatively or.changeably to identify the appropriate.level or intensity of treatment for.clients some places require it some.places is optional I find it very.helpful if for nothing else than to.document in a very consistent way across.charts that this is what I look at and.yes I looked at all these aspects when I.did the case formulation treatment.intensity does not necessarily equal.treatment program placement so if.somebody scores out for residential that.may not be where they are going to be.best served from an individual.culturally respective respectful.standpoint so recognize that all these.tools are just guidelines and like I.said earlier a lot both of those tools.point you towards higher intensity.levels of care for people who are less.motivated and you may run into a client.who's just very involuntary and is not.going to benefit from residential care.so you want to take all those factors.into consideration and yeah you'll have.to justify why you deviated from the.recommendations but that's usually one.or two sentences insurance companies.often define the services to be provided.each level of care for reimbursement.purposes but states may Florida is a.perfect example in 65 - 30 where it's.the state of Florida actually define.certain services that have to be.provided at certain levels of care.so you can listen to this again if you.really want to on the counselor toolbox.podcast which is put out every Saturday.you can like our Facebook page to find.out about upcoming courses you can.subscribe to our YouTube channel the.Friday after the course is taught the.video version the video replay is.uploaded to YouTube so you can go if you.really want to watch it over again.and you can access CEUs and certificate.training and all CEUs calm if you enjoy.this podcast please like and subscribe.either in your podcast player or on.youtube you can attend and participate.in our live webinars with dr. Snipes by.subscribing at all CEUs comm slash.counselor toolbox this episode has been.brought to you in part by all CEUs comm.providing 24/7 multimedia continuing.education and pre certification training.to counselors therapists and nurses.since 2006 use coupon code consular.toolbox to get a 20% discount off your.order this month.

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How do very mixed race people fill out official documents and forms that ask for race if one is only allowed to choose one race?

I cant answer for everyone but I always answer my dads race (asian/filipino) because of two reasons. My dad is where I get my last name and thus my tribe in a way. Plus I resemble my dad's family more than my mom's. I am not close at all with my mother's family and I grew up in almost entirely Filipino culture.

As one of the cofounders of a multi-member LLC taxed as a partnership, how do I pay myself for work I am doing as a contractor for the company? What forms do I need to fill out?

First, the LLC operates as tax partnership (“TP”) as the default tax status if no election has been made as noted in Treasury Regulation Section 301.7701-3(b)(i). For legal purposes, we have a LLC. For tax purposes we have a tax partnership. Since we are discussing a tax issue here, we will discuss the issue from the perspective of a TP. A partner cannot under any circumstances be an employee of the TP as Revenue Ruling 69-184 dictated such. And, the 2016 preamble to Temporary Treasury Regulation Section 301.7701-2T notes the Treasury still supports this revenue ruling. Though a partner can engage in a transaction with the TP in a non partner capacity (Section 707a(a)). A partner receiving a 707(a) payment from the partnership receives the payment as any stranger receives a payment from the TP for services rendered. This partner gets treated for this transaction as if he/she were not a member of the TP (Treasury Regulation Section 1.707-1(a). As an example, a partner owns and operates a law firm specializing in contract law. The TP requires advice on terms and creation for new contracts the TP uses in its business with clients. This partner provides a bid for this unique job and the TP accepts it. Here, the partner bills the TP as it would any other client, and the partner reports the income from the TP client job as he/she would for any other client. The TP records the job as an expense and pays the partner as it would any other vendor. Here, I am assuming the law contract job represents an expense versus a capital item. Of course, the partner may have a law corporation though the same principle applies. Further, a TP can make fixed payments to a partner for services or capital — called guaranteed payments as noted in subsection (c). A 707(c) guaranteed payment shows up in the membership agreement drawn up by the business attorney. This payment provides a service partner with a guaranteed payment regardless of the TP’s income for the year as noted in Treasury Regulation Section 1.707-1(c). As an example, the TP operates an exclusive restaurant. Several partners contribute capital for the venture. The TP’s key service partner is the chef for the restaurant. And, the whole restaurant concept centers on this chef’s experience and creativity. The TP’s operating agreement provides the chef receives a certain % profit interest but as a minimum receives yearly a fixed $X guaranteed payment regardless of TP’s income level. In the first year of operations the TP has low profits as expected. The chef receives the guaranteed $X payment as provided in the membership agreement. The TP allocates the guaranteed payment to the capital interest partners on their TP k-1s as business expense. And, the TP includes the full $X guaranteed payment as income on the chef’s K-1. Here, the membership agreement demonstrates the chef only shares in profits not losses. So, the TP only allocates the guaranteed expense to those partners responsible for making up losses (the capital partners) as noted in Treasury Regulation Section 707-1(c) Example 3. The chef gets no allocation for the guaranteed expense as he/she does not participate in losses. If we change the situation slightly, we may change the tax results. If the membership agreement says the chef shares in losses, we then allocate a portion of the guaranteed expense back to the chef following the above treasury regulation. As a final note, a TP return requires knowledge of primary tax law if the TP desires filing a completed an accurate partnership tax return. I have completed the above tax analysis based on primary partnership tax law. If the situation changes in any manner, the tax outcome may change considerably. www.rst.tax

The company I work for is taking taxes out of my paycheck but has not asked me to complete any paperwork or fill out any forms since day one. How are they paying taxes without my SSN?

If no paperwork has been filed since Day 1 and from what you said (How are they paying taxes without my SSN?), they don’t have your SSN, are you sure they consider you an employee and not an independent contractor? I’ve known many employers to do this to get out of paying unemployment insurance, health insurance and their share of FICA. They can still be required to withhold taxes if they don’t have a tax ID for you, in the same way that a company will withhold taxes and remit them when they pay dividends on a shares owned by a non-citizen.

How do I fill out Form 16 if I'm not eligible for IT returns and just want to receive the TDS cut for the 6 months that I've worked?

use File Income Tax Return Online in India: ClearTax | e-Filing Income Tax in 15 minutes | Tax filing | Income Tax Returns | E-file Tax Returns for 2014-15 It is free and simple.

Can a first year BHMS student fill NEET UG Form? If yes then how will they get their original documents for counseling. Do they need to have TC from honopathic college or TC of school will work.

You can apply for the exam without any original documents. At the time of admission, You can provide your affidavit of appearing in BHMS. Your application will be accepted for the admission. You will need to provide TC of homeopathic college to get admission in 2018 counselling process.

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