DIAGANOSIS Case Study Psychotherapy

On 6/30/2016, CM met with the client to complete to Bi-Weekly ILP Review. In the meeting, client was dressed appropriately for the weather. She was very loquacious and client. Client appears to have difficulty sustaining attention, client does not seem to listen when spoken to directly and she is unable to follow through on tasks. Client affect is inappropriate and she denied suicidal or homicidal ideation.

I: CM guided client through ISP goals. CM inquired about updates related to the client’s housing goals. CM used open ended questions to inquired about the client most recent drug use. CM reminded client that starting Monday the 2nd he would have to meet with CCM for weekly case management going forward. CM continued to assess for PTSD symptoms, substance abuse, and medication compliance.

Mental Health Update: Client was diagnosed with Clinical Depression and client reported she wasn’t attending her mental health counseling at BATF (“Bridging Access to Care”).

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.

Counselor red flagged pt. and requested that he meet for brief TX intervention to discuss his current counseling non-compliance status and explaining the risk of discharge from the program if he fails to do an individual session by 1/22/17. AMS receptionist told this writer that pt. is asking why he needs to meet with this writer. This writer told him to inform him that if he fails to complete one hour individual session by 1/22/17 he will be subject for a TX discharge. Pt. refused to meet with this writer and he failed to schedule an individual session on the above date.

Bensalih reported that she has completed her rule 25 assessment at Tubman and has upcoming treatment sessions with her therapist and with her group. Also, CPSW asked Ms. Bensalih her process regarding Associate clinic psychology. Ms. Bensalih reported that she has not seen her therapist lately and planning to go back and schedule appointment with Associate clinic associate asap. Ms. Bensalih reported that she will let this writer know her up coming appointments with tubman and ASC. CPSW encouraged Ms Bensalih to go back at Associate Clinic Associate for the mental health assessment. CPSW asked about her supervision and needing to schedule appointment asap. Ms. Bensalih stated that she has been busy and stressed about all the work she needs to complete regarding the

: 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

CM was out on vacation from 5/3/2017 to 6/14/2017. On 6/20/2017, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed in proper attire for the weather. Her affect and mood was appropriate. Client maintains eyes contact appropriately and she was oriented to person, place, time and situation. Client continue to deny suicidal or homicidal ideation

Mental health: Client reported that he is currently waiting for an appointment for MH services from his OTP. The client reported his intention to continue attending a PTSD support group while in the program. Client denied having any S/I and H/I at this time.

The patient was placed on HOLD to see the writer to address his non-compliance with treatment. The patient was reminded about his Step 3 of the patient engagement. According to the patient as the writer reviewed the patient case history of his no show for counseling, group attendance, and continuously AWOL, the patient only response was, " I, know." The writer then inquired of the patient efforts to engage in mental health services through ICRC. The patient admits that he haven't done the intake when the deadline was extended for the third time. The writer discussed with the patient about the risk of facing an intent to discharge due to his non-compliance and addressed alternatives such as suboxone and transferring to a clinic in Massachusetts to accommodate the work location. The patient declines the writer's suggestion as he wants to remain with HCRC-Hartford due to the positive treatment and said. " You guys really care....I do not want to be discharge.....I, mean what is the process of the intent of discharge?" The writer explained to the patient about the appeal process as his record will be reviewed by the Practice Manager to determine as to whether or not to forward with the discharge or the discharge to be overturn.

MENTAL UPDATE: Client was recently diagnosed by the on-site psychiatrist with Axis 1: Minimal cognitive impairment; 331.83 (primary) rule out and Anxiety about health -300.09 vs. illness anxiety d/o vs. pt seeking secondary gain. No referral or medication was prescribed.

First, we will examine my initial clinical note on 8/15/16 with client, Rhonda Smith, session one. During this first session, I collected Rhonda’s demographic and intake information (Murphy & Dillon, 2015; Reamer, 2001). This included a signed consent for treatment, which we reviewed and all her questions were answered, as well as signed medical releases for previous therapy and agency records, i.e., DVIS, CPS, CASA, that will be requested (Murphy & Dillon, 2015; Reamer, 2001). Additionally, she was informed about HIPAA, patient privacy rights, billing practices, professional boundaries and expectations, and how to contact me during business hours, and after-hours crisis lines, and on-call assistance phone numbers for resources if it is outside of my business hours (Murphy & Dillon, 2015).

D-The patient was placed on HOLD to see this writer to address her no show for counseling on Friday and missed dose as well. According to the patient, she had transportation issue. The patient admitted that she relapsed by using crack cocaine-$20 bags by smoking. Addressing the relapse is due to stressor of her current residency with her "baby-daddy," according to the patient. Alternatives were discussed. The patient asked this writer for assistance again for the contact number to CHR and CVS of which this writer provided. In addition, this writer questioned the patient about her living situation as she reported about it being a stressor in her life. According to the patient, she is no longer residing at her "baby-daddy" resident as she reported

Psychiatric- patient is a little anxious about these new symptoms and their significance. We discussed her situation and I offered her psychologic services, she refused for now.

The Beck Anxiety Inventory is a 21-item scale that measures the severity of self-reported anxiety in adults and adolescents. The inventory was created by Aaron T. Beck and his colleague, Robert A. Steer, at the Center for Cognitive Therapy, University of Pennsylvania School of Medicine, Department of Psychiatry. The most recent edition was published in 1993 by The Psychological Corporation, Harcourt Brace & Company in San Antonio, TX. The first edition was published in 1988. The 1993 edition recommends different scoring guidelines than previous editions. There is only one form and one manual as part of the Beck Anxiety Inventory (BAI). To purchase the BAI in 2010, the manual and 25 scoring sheets