What to Look for in a Rehab Centre’s Written Treatment Plan

Many families only see a written treatment plan in rehab once admission is over and the first worried week has passed. Some never see one at all. Whether a centre hands you a neat folder or a single photocopied sheet, the document tells you a great deal about how the team thinks about your loved one: as a person with a particular history, or as one more bed to fill.

This guide does something different from a checklist. Below is a fictional sample plan, built section by section for an illustrative patient, with a short annotation after each part explaining what to check and what should worry you. Use it alongside the plan you have been given, or the one you are about to ask for.

How to use this annotated sample treatment plan

Read each sample section and its “What to check” box, then find the matching part in your own document. Note any gaps; they become your questions for the treating team.

For example, imagine a man we will call “Patient R”. He is 38, lives with his parents, wife and two children in a joint family in Ghaziabad, works in sales, and has been drinking heavily for about eight years. His wife and elder brother brought him for an assessment after a fall at home. He agreed to stay. Everything that follows is his invented, illustrative plan, not a template for anyone’s real care.

Section 1: Identifying details and admission type

Sample entry:

• Name: Patient R (illustrative) | Age: 38 | Sex: Male
• Date and time of admission: recorded on the day
• Admission category: Independent admission under the Mental Healthcare Act 2017
• Consent: Admission and treatment consent discussed in Hindi and English; patient signed; capacity judged adequate by the admitting psychiatrist
• Nominated representative: Wife (name and phone recorded)
• Emergency contact: Elder brother
• Treating psychiatrist: named, with medical council registration number
• Key worker / primary counsellor: named

What to check: The admission type should be written in plain words. Under the Mental Healthcare Act, independent admission under section 86 is the default for an adult who can make decisions, and that person can ask to leave. If the plan says “supported admission”, there should be a record of the nominated representative’s application and assessments by two professionals as the law requires. A blank space where consent should be, or a family member’s signature in place of the patient’s, is a serious warning sign. Look for a named psychiatrist and a named key worker, not just “doctor on duty”.

Section 2: Assessment summary

This is the foundation of any written treatment plan in rehab: every later goal and intervention should trace back to something found here.

Substance use history

• Primary substance: Alcohol (whisky), roughly a full bottle on most days in the last six months
• Pattern: Morning drinking for three months; hidden bottles at home and in the car
• Other substances: Occasional cannabis in his twenties, none in the last five years; tobacco (gutka) daily
• Last drink: Evening before admission
• Previous attempts to stop: Two home attempts; one ended with shaking and confusion on day two

Severity and withdrawal risk

• Diagnosis: Alcohol dependence, with severity documented by the psychiatrist
• Withdrawal scale at admission: CIWA-Ar score recorded, repeated at set intervals
• Risk factors noted: history of confusion during a past withdrawal; heavy daily use; poor food intake
• Withdrawal risk rating: High, so medically supervised detox advised

Physical health

• Liver function tests raised; ultrasound requested
• Poor diet and weight loss, so thiamine started on day one

Mental health and risk assessment

• Low mood for over a year, poor sleep, guilt; screen for depression to be repeated after detox, because withdrawal can mimic or worsen low mood
• Suicide risk screen: passive thoughts in the past month, no plan, no attempts; re-screen weekly
• Social: debts, job at risk, strained marriage, supportive brother

What to check: A good assessment summary is specific. It names the substances, the amounts, the date of last use and any past complicated withdrawal, because these shape how risky detox will be. The American Academy of Family Physicians review on alcohol withdrawal explains why scales such as CIWA-Ar are used and why a history of seizures or delirium raises risk. Look for physical tests, a mental health screen and a written suicide-risk assessment. If the summary is two lines long (“alcohol addict, needs treatment”), the rest of the plan is probably guesswork.

Section 3: Problem list

Sample entry:

1. Alcohol dependence with high withdrawal risk
2. Possible alcohol-related liver injury
3. Nutritional deficiency (thiamine risk)
4. Low mood: possible depressive disorder versus alcohol-induced symptoms, to be clarified
5. Passive suicidal thoughts
6. Sleep disturbance
7. Marital conflict and loss of trust within the family
8. Financial stress and job at risk
9. Daily tobacco use

What to check: The problem list turns the assessment into things the team will actually work on. It should include medical, psychological, family and practical problems, not just “addiction”. Notice that a co-occurring mental health concern (here, low mood) is listed with a plan to clarify it. Look for this in your own document: if your relative has anxiety, depression, trauma or psychosis and it does not appear, ask why. Problems the patient names himself, such as debt or work, deserve a place too.

Section 4: Treatment goals in addiction care, written as SMART goals

Good treatment goals for addiction recovery are SMART: specific, measurable, achievable, relevant and time-bound. Vague goals such as “stay sober” or “improve behaviour” cannot be reviewed, so nobody can tell whether treatment is working.

Short-term goals (first two to three weeks)

• Complete medically supervised withdrawal with no seizures or delirium; withdrawal scores to fall to the mild range and stay there for 48 hours before medicines are tapered off
• Take thiamine and other prescribed medicines as charted, every day
• Repeat liver tests at the end of week two
• Attend at least five individual or group sessions a week from day five onwards
• Sleep at least six hours a night by the end of week two, measured by nursing notes
• List personal drinking triggers with the counsellor by day ten

Long-term goals (by discharge and the three months after)

• Agree a written relapse prevention plan naming at least three high-risk situations and a specific response for each
• Decide, with the psychiatrist, whether to start anti-craving medicine and how it will be monitored after discharge
• Hold at least two family sessions before discharge, including one about money and trust
• Attend weekly outpatient follow-up for the first three months
• Return to work with a plan agreed with the patient for handling client entertainment where alcohol is served

What to check: Each goal should answer three questions: what exactly will change, how will we know, and by when. Count how many of your plan’s goals have a number or a date. Goals should also sound like the person. If Patient R’s goals mention client dinners and his family’s trust, and your relative’s goals could belong to anyone, the plan has probably been copied from a template. Our sibling guide on why a single programme should not be prescribed to every patient explains why this matters clinically.

Section 5: Interventions

This is where the plan says what the team will do. A useful individual treatment plan in rehab separates medical, psychological, family and holistic work, so you can see that each problem has a matching response.

Medical interventions

• Medically supervised detox using a symptom-triggered protocol, with regular CIWA-Ar scoring and vital signs
• Thiamine started before glucose-containing fluids, and continued as prescribed
• Review of anti-craving options (for example naltrexone or acamprosate) after liver results are back; choice to be discussed with the patient, including side effects
• Liver ultrasound and repeat blood tests
• Nicotine replacement offered for tobacco
• Repeat depression screen after detox; psychiatric review if low mood persists

Psychological interventions

• Motivational interviewing sessions in week one and two to explore his reasons for change
• Cognitive behavioural therapy focused on triggers, thoughts that lead to drinking, and low mood
• Relapse prevention skills: urge surfing, refusal practice for work situations, planning for festivals and weddings
• Group therapy, at least three sessions a week

Family interventions

• Family assessment with wife and brother in week one
• Psychoeducation sessions for the family on dependence and withdrawal
• Couple session on communication and finances before discharge

Holistic and supportive interventions

• Daily yoga or light exercise once medically cleared
• Diet plan and sleep routine

What to check: Every problem from Section 3 should have at least one intervention here. Look for a medical section, even if the person is “only” drinking; alcohol withdrawal can be dangerous, and the NHSRC Standard Treatment Guidelines on alcohol dependence treat it as a medical condition with specific management steps. Medicines such as naltrexone and acamprosate should be prescribed by a doctor after checking the person’s health, and the plan should say who decides. You can read more about medicines used in alcohol addiction treatment. Holistic activities are welcome additions, but if yoga and prayer are the only interventions listed, the plan is missing its core.

Section 6: Who is responsible for each item

Sample entry (extract):

• Detox protocol and medicines: treating psychiatrist (named); nursing team carries out scoring
• Liver tests and physical review: medical officer (named)
• Motivational interviewing, CBT and relapse prevention: primary counsellor or psychologist (named)
• Family sessions: family therapist or social worker (named)
• Discharge and aftercare coordination: key worker (named)

What to check: A plan without names is a plan without accountability. Each line should show a role and ideally a person. If everything is assigned to “staff” or “team”, ask who you should call about each part. It also helps to understand what psychiatrists, psychologists and counsellors each do, so you can see whether the right professional has been given the right task.

Section 7: Review dates and how progress is measured

Sample entry:

• Daily: withdrawal scores, vitals, sleep and medicine record (nursing)
• Day 7: first multidisciplinary review with patient; detox progress, mood re-screen, goals adjusted
• Day 14: second review; liver results, medicine decision, family session update
• Then weekly until discharge
• Progress measures: withdrawal scale, mood questionnaire, session attendance, counsellor’s notes on trigger list and relapse plan, family feedback
• Rule: length of stay to be decided at reviews, based on progress against goals, not fixed at admission

What to check: The NIDA Principles of Drug Addiction Treatment make the point that a plan should be assessed continually and changed as the person’s needs change. So a rehab care plan review should have actual dates, and you should be told what changed at each one. If your document has no review dates, or the length of stay was fixed at 30, 60 or 90 days before anyone assessed the patient, ask how progress will be judged.

Section 8: Patient and family involvement, and signatures

Sample entry:

• Plan discussed with patient on day three (after the worst of withdrawal) in Hindi; patient’s own words recorded: “I want to stop before I lose my job and my children’s respect.”
• Patient agreed to goals; disagreed with the weekly urine test schedule; compromise noted
• Family meeting on day five; wife and brother given a copy with the patient’s permission
• Signatures: patient, treating psychiatrist, primary counsellor; date on each

What to check: The patient should have helped write the plan, not just signed the last page. Look for evidence of discussion, such as the patient’s own words or a disagreement that was resolved. Family involvement is valuable in Indian households, where recovery happens at home, but it should happen with the patient’s consent. The joint UNODC–WHO treatment standards describe treatment that is ethical, based on informed consent and individualised. A plan signed only by a relative is not good practice for an adult who can decide for himself. Family counselling should be written in as a real part of treatment, with dates.

Section 9: Discharge criteria and aftercare plan

Sample entry:

• Discharge when: detox complete and stable; medicine decision made; relapse prevention plan written; at least two family sessions done; follow-up booked
• Planned discharge: estimated at reviews, not fixed in advance
• Aftercare: weekly outpatient counselling for three months, then fortnightly; psychiatrist review at two and six weeks; medicine monitoring including blood tests if prescribed
• Home changes agreed with family: no alcohol stored at home; brother to manage cash for the first month (patient agreed)
• If the patient leaves early: the team will still give a summary, medicines and an outpatient appointment

What to check: Detox is only the first step, not the whole treatment, and the period after discharge is often when people struggle. Look for named follow-up dates, a plan for medicines after discharge and a written relapse prevention plan. Second New Life’s aftercare planning and relapse prevention programmes give you a sense of what this stage should cover. “Discharge after 90 days” with nothing after it is not an aftercare plan.

Section 10: Crisis and safety plan

Sample entry:

• Warning signs for patient and family: craving that will not settle, isolating, stopping medicines, talking about hopelessness
• Steps: call the key worker or the centre’s helpline; contact the outpatient psychiatrist; the brother stays with him
• Medical emergency: for seizures, confusion or hallucinations, chest pain, vomiting blood, signs of overdose, or any thought of self-harm with intent, call 112 or go to the closest hospital emergency unit straight away
• Free helplines: Tele-MANAS 14416 (mental health, 24×7) and the de-addiction helpline 14446
• If a slip happens: tell the team; a slip is treated as information for the plan, not a reason for punishment

What to check: The safety plan should be short, practical and known to the patient and the family. It should name who to call and when to go straight to hospital. Look for a written suicide-risk response if any risk was found during assessment. If the plan treats relapse as a disciplinary matter, that tells you something about the culture of the centre.

Quick reference: what should a treatment plan include?

If you only have a few minutes with your document, use this table. It works as a fast rehab treatment plan example to compare against.

Section	What good looks like	Red flag
Admission and consent	Admission type under MHCA stated; patient’s own signature; named psychiatrist	Only a relative’s signature for a capable adult; no admission type
Assessment summary	Substances, amounts, last use, past withdrawal, physical and mental health, risk screen	Two-line summary; no withdrawal risk; no suicide screen
Problem list	Medical, psychological, family and practical problems, including co-occurring illness	Only “addiction” listed
Goals	Specific, measurable, dated, in the patient’s own terms	“Stay sober”, “be disciplined”, same goals as every other resident
Interventions	Medical, psychological, family and holistic, linked to problems	No medical section; only lectures, prayer or chores
Responsibility	Each item has a role and a named person	“Staff” or “team” for everything
Reviews	Dated reviews; measures stated; length of stay set by progress	No review dates; stay fixed before assessment
Involvement	Patient helped write it; family role with consent	Patient never saw it
Discharge and aftercare	Clear criteria; booked follow-up; medicine plan	No aftercare at all
Safety plan	Warning signs, contacts, 112 for emergencies	Missing, or relapse listed as a punishment trigger

Ten signs a plan is just paperwork

Some centres produce a plan only because a regulator or insurer expects one. These signs suggest the paper and the treatment are unrelated.

1. Copy-paste goals. The same phrases appear for every resident, sometimes with another person’s name or the wrong substance left in.
2. No review dates. Nothing in the document says when it will be looked at again.
3. No named clinician. No psychiatrist, doctor or counsellor is identified by name or registration.
4. No medical section. There is no detox protocol, no medicine list and no physical tests, even for alcohol or benzodiazepine dependence.
5. No mention of co-occurring illness. Depression, anxiety, trauma or psychosis is ignored, even when the family reported it.
6. Punishments listed as “therapy”. Isolation, extra chores, head-shaving, loss of phone calls or physical “discipline” appear as treatment. Under the Mental Healthcare Act, practices such as seclusion are not allowed, and these have no place in any plan.
7. Fixed length regardless of progress. The stay is set at a round number of days before assessment and never changes.
8. No family role. The family is told to stay away, with no planned sessions or education.
9. No aftercare. The plan ends on discharge day.
10. Not shared with the patient. The person being treated has never seen or discussed it.

One or two gaps in a written treatment plan in rehab can be fixed by a conversation; several together suggest a deeper problem. If you are weighing options, our guide to weighing two treatment proposals against each other can help you judge which one has substance behind it.

Your right to see and understand the written treatment plan in rehab

A plan is not a secret file. In India, several layers of law and professional rules support a patient’s right to know what treatment is being given and why.

Informed consent

Consent means more than a signature. The person should understand the main treatments, the likely benefits, possible side effects and the alternatives, in a language they follow. For an adult admitted independently, consent to treatment is the default rule, and they can withdraw it.

Rights to information under the Mental Healthcare Act

Because substance use disorders fall within the Mental Healthcare Act 2017, de-addiction centres count as mental health establishments. The Act gives patients and their nominated representatives a right to information about the provision under which they were admitted, the nature of the illness and the proposed treatment plan, including likely side effects. It also provides a right to access basic medical records, with limited exceptions. For supported admission, the role of the nominated representative is set out in section 89, and that person should be kept informed and involved.

Access to records

Regulation 1.3.2 of the 2002 IMC ethics regulations says a doctor should hand over medical records within 72 hours once the patient or an authorised person requests them. The health ministry’s draft Charter of Patients’ Rights refers to this rule. In practice, ask politely in writing for a copy of the plan and the discharge summary, and keep a note of when you asked.

Confidentiality still applies: an adult patient can choose what is shared with family.

How to ask for changes to the plan

You do not need a medical degree to ask good questions. Most teams welcome families who engage respectfully.

1. Read the plan with the patient if possible. His view matters most, and he may already have concerns.
2. Mark gaps using the table above. Write down which sections are missing or vague.
3. Ask for a meeting with the key worker or psychiatrist. Request a time, rather than raising it in the corridor at visiting hour.
4. Frame questions around goals. For example: “How will you know the low mood is improving?” or “When will the medicine decision be made?”
5. Share information the team may not have. Past withdrawal fits, medicines from other doctors, family history of mental illness or recent stressors can change the plan.
6. Ask for the change in writing. An agreed change should appear in the next version with a date.
7. Escalate if needed. If concerns about rights or safety are not addressed, speak to the centre’s head, and if necessary to the State Mental Health Authority or the Mental Health Review Board.

If you want to understand the thinking behind good plans, our sibling piece explaining evidence-based addiction treatment for Indian families covers which approaches have research support and why plans should be built on them.

When the plan needs more than small changes

Sometimes the conversation shows that the centre cannot treat a key problem, such as a serious psychiatric illness alongside addiction. In that case, ask whether a specialist dual diagnosis programme is needed, or whether a hospital review should come first. A centre that admits its limits is often safer than one that claims to treat everything.

Frequently asked questions

When should we receive a written treatment plan?

An initial plan is usually drafted after the admission assessment, often within the first few days, and refined once withdrawal settles. Ask the centre when the first version and first review will happen. If nothing exists after the first week, ask why.

Can the family see the plan if the patient is an adult?

An adult with capacity decides what is shared. Many patients agree to share the plan with close family, and centres should ask. For supported admission, the nominated representative has a recognised role in being informed and involved.

What are SMART goals in addiction recovery?

SMART goals are specific, measurable, achievable, relevant and time-bound. Instead of “stay sober”, a SMART goal might be “attend weekly outpatient follow-up for three months after discharge”. This makes progress easy to review and discuss.

Should every addiction treatment plan in India include medicines?

Not always, but every plan should include a medical assessment. Some people need medicines for withdrawal, cravings or a co-occurring illness; others may not. The decision should be made by a doctor, explained to the patient and recorded with reasons.

How often should a rehab care plan be reviewed?

There is no single rule, but reviews should be dated and frequent enough to respond to change, often weekly during a residential stay. Each review should note progress against goals and any changes made.

Can we get a copy of the plan and records?

Yes. Under Indian medical ethics rules, records should reach you within three days of asking, and the Mental Healthcare Act recognises access to basic medical records. Put the request in writing and keep a dated copy.

What if the plan lists punishments as treatment?

Punishments such as isolation, forced labour, head-shaving or beatings are not treatment and may breach patients’ rights under the Mental Healthcare Act. Raise it with the centre’s head immediately and, if needed, inform the State Mental Health Authority or the police.

Talk to Second New Life about a personalised treatment plan

At Second New Life, our personalised treatment plans are built from a detailed assessment and discussed with the person receiving care. Whether you hold a plan from elsewhere that you want explained, or you are only beginning to look for help, our admissions team is happy to go over it with you.

Phone +91 84481 77994, WhatsApp +91 98213 98997, or send us a message through the contact form. If anyone is in immediate danger, call 112 first.

Disclaimer: The sample plan above is fictional. This page offers general guidance, not medical or legal advice, and cannot replace a full assessment by qualified professionals. In a medical emergency dial 112 or reach the closest hospital emergency unit; for mental health support, Tele-MANAS is on 14416.