Annual Assessment Template
Pt. is a 46-year-old divorced white female, who has been enrolled in medication-assisted treatment at
the agency for the past 84 months. Pt. currently lives independently, in private residence, and has no
dependent children. Pt. has earned a high school diploma and has no difficulty reading, writing, or
comprehending material. Patient is self employed, part-time, and has been throughout the last 12
months. Pt. has a valid driver’s license and means of transportation. Pt. receives public assistance in the
forms of food stamps and State medical insurance. No military history. Pt. denies past/present suicidal
thoughts or ideations and reports no mental health treatment or concerns. Pt. has not experienced or
witnessed any traumatic events within the past year. Pt reports no health concerns. Pt. receives 105
mg of Methadone daily by the facility and has earned Phase 4 status. Pt.’s DOC is Percocet via oral
route. Pt has had 6 months of abstinence from her DOC which ended due to the stress of a divorce. Pt.
uses medical marijuana and states she has a valid prescription, yet has failed to provide documentation.
Pt. has immediate access to Narcan at home. Pt. use nicotine/tobacco products and has reduced her
use to 5 per day. Patient denies any legal conflict within the past year. No present probation or parole.
Patient identified “improved health and hard worker” as strengths. She indicated a need to move to
another state. Patient has the ability to work well with others. She prefers to continue medicationassisted treatment as is. Pt. this past year feels she has gained/benefited from treatment. Patient
stated, “I have gotten my life back, life is getting easier” Pt.’s goals for the next year is, “to stick with
what I'm doing and hit more groups.”