CFS Case Studies

Client comes to treatment because she has been mandated by the court to receive services for her drug and alcohol usage. Client self-reports an extensive history of drug and alcohol usage, as well as, issues with controlling and maintaining her anger. Client is more concerned with her anger issues then her drug and alcohol usage. Client feels that if she can control her anger then she will not have to turn to drugs and alcohol. Client appears to be self-medicating with drugs and alcohol.

Substance use history: Charlie substance use began when he started his freshman year in high school when his new friends introduced it to him. He has experimented with marijuana, LSD, and alcohol. Client has no preferred drug of choice and only participated in substance use when it was given to him on a few occasions. When on LSD he began to hallucinate and the flash backs of his aunt caused him to pass out on the side of the road where the police found him the next morning. No charges where filled.

Ms. Client is a twenty-two-year-old, Caucasian female was referred for a psychological evaluation by Dr. B., Clinical Psychiatrist and her therapist for her excessive use of cocaine, Xanax and other substances. Dr. B. stated Ms. Client has been experiencing loss of interest, feeling like a failure and frequently crying. Additionally, she complains that her struggle with substance abuse has impacted her social, emotional and behavioral functioning. Ms. Client was admitted to the facility following a relapse. This is her sixth substance abuse treatment program. The purpose of the current evaluation is to (1) assess present level of functioning, (2) determine diagnostic impressions, (3) to identify relevant treatment and service needs.

Client had mumps at 11years old and chicken pox at the age of 8 and she did not require hospitalization for both illnesses. Client was hospitalized for 3 days in 2014 when she hysterectomy due to menorrhagia and fibroids

The counselor met with the patient for her scheduled Addiction Severity Index assessment. The patient is a 54 year old black male. The patient states he is single with no children. He report currently lives with sister in law of his decease brother. The patient reports having a 14 years of education however no degree. The patient report receiving disability for mental health disorder. The patient reports he is currently not on probation. The patient reports he last use Cannabis 7/17/15 and started using at the age of 13 and smokes 3 to 4 times a week at least 2 joints. He also report using Alcohol 7/20/15 a 40oz beer and usually drank a couple a day. The patient denies any issues with HI/SI. Patient also reports he is taking his medication as prescribed. The patient appear to be in the pre-contemplation stage of change. The patient next scheduled individual session with the counselor is on Monday, July 27, 2015 at 02:30p

appeared her stated age and appeared in good health. She was in no acute distress. She was alert, satisfactorily groomed, and casually dressed. She was cooperative and appropriate in the meeting. She had normal motor activity, with no unusual gestures or mannerisms. She made eye contact appropriately. her affect was appropriate. Client ambulates with a cane. She was oriented to person, place, time and situation. She denied suicidal or homicidal ideation.

This physician must evaluate all the above listed for the consult with the primary care doctor. Including competency and diagnosis.

: Met with client before IOP group this date for ISP review, and to address overall treatment progress. Presented a good attitude and engaged well in the conversation. Reported no use of Methamphetamine or other substances, C/S date as 2/28/2018, although UA on 03/21/18 was positive for methamphetamine. Client reported he is excited that he is in treatment, stating “I never been to treatment before. I would like to learn about the addiction, but I am also affair of treatment because I am worried that I won’t make it.” Client reported main arears of concern is “staying clean and sober and complete treatment”. Stated “My ex-girlfriend is not supportive, and she drives me crazy. I work and pay the bills, but she never happy. She asked me to do this to do

Client was considered to be in semi-compliance with treatment during this reporting period. Client attended two secheduled groups with two absences. UA were negative for all tested substances. Client reported participating in self-help meeting regularly; verification was provided. Treatment attendance needs to be improved in 30 days.

The client has high motivation for treatment within MRFH. The client was diagnosed with Alcohol Use Disorder: Severe and Cocaine Use Disorder (crack): Moderate. The client sought treatment at MRFH when he realized he had lost control of using alcohol and crack cocaine. The client stated he attended the MRFH program in the 1980 's but does not remember the exact date of attendance. The client stated he was diagnosed with Mild Depression by a primary care physician when he was 56-years-old. The client reports he has no history of suicidal or homicidal attempts, and currently denies having any suicidal ideations or homicidal ideations. The client stated one to two times per week he experiences muscle tension and worrying about things that he often realizes have no significance. The client stated prior to the age of 18-years-old, "I would knock over my neighbors mailboxes and destroy their gardens, because they would make my parents aware of my wrong doings and that was way of getting them back." The client stated, there was one time that I started a fire and blamed it on my brother. I would break things as well and blame someone else. The client stated if there was an event taking place that he wanted to participate in, he would rush and complete what he was doing so he could become involved in other events taking place around him. The client stated, "I started using drugs and alcohol without thinking about what the consequences. The client appeared to be oriented to the

She remember enjoying the experience but reports continued experimentation with drugs two or three times per month until college there she stopped drinking following a binge-drinking episode prior to leaving for college in which she reports drinking until she passed out. Following this incident, she reported finding drinking sickening. Then drugs came into play. She now reports using drugs primarily on occasions, along with alcohol. Last use was two months ago, one glass of wine at a holiday party. No current abuse or dependency on drugs and alcohol. Client reports experimentation with weed in high school when her parents divorced. She did not like the taste or smell and reports it made her sick, so she did not continue. Client reports regular use of pain killers, up to six pills per

D.D. is a 50-year-old, African American male presenting with a number of anxiety and depressive symptoms. The client reports that he came to counseling for “extra support and someone to talk to.” D.D. has been struggling with mental health issues since he was young. Since the age of 15 he has been hospitalized on and off for “hearing voices.” In the early 1980’s he was diagnosed with schizophrenia and prescribed Risperdal to treat the symptoms. Since then, D.D. has been in a variety of mental health settings, including hospitals, day programs, and outpatient treatment. The client has an extensive alcohol and drug use history that he believes impacted his Schizophrenia. In the early 1980’s the client would use alcohol every day “to avoid the voices,” drinking “anything he could get his hands on.” He was also heavily involved with drugs at that time and regularly used marijuana, PCP, cocaine, and heroine. In 2000, the client was sentenced to eight years in jail for four bank robberies. While in jail, D.D. received mental health treatment and alcohol and drug treatment, which was greatly beneficial. When the client was released from jail in 2008, he was drug and alcohol free and was taken off of Risperdal.

Five year old Ellis Miles undergoes numerous treatments each day to counteract the symptoms that accompany cystic fibrosis including physiotherapy, pills containing digestive enzymes, and a treatment which breaks up the mucus in her lungs. Cystic Fibrosis has numerous life threatening symptoms and while there is no cure, there are several treatments that a typical patient undergoes each day to combat these symptoms. The most prominent symptom associated with Cystic Fibrosis is a thick mucus that clogs up tubes that carry out crucial roles in the human body. This mucus especially affects the respiratory tract. Mucus builds up in the respiratory tract making it difficult for individuals with cystic fibrosis to have a frequent cough that produces a thick

History of Present Illness: The patient has been seen in this clinic since 2016. She is diagnosed to have ADHD, Bipolar II disorder, Generalized Anxiety disorder, Alcohol and Cannabis use dependence. The patient has struggled with separation from an abusive ex-husband, who is currently

Patient also, has history of hypertension, GERD, morbid obesity, anemia, and depression. She reported that the past few months, she has been feeling very weak and overall generalized deconditioning. Her ability to care for herself including her activities of daily living (ADLs), and her basic physical needs (like bathing, grooming, ambulation, meal preparation, transportation, errands, and housekeeping), had decreased, and cannot consistently carry them out.