Drug Free Status Active Case Study

Plan - The counselor Interventions until next review: Client is to continue current level of treatment to fulfill the court requirement. Counselor will work closely with the probation officer to help the client to complete his treatment successfully. Counselor will continue to motivate and educate to address alcohol use disorder and support remission and long-term

The participant is a 49 year old African American male who began using substances at the age of 13. He was diagnosed with severe alcohol, cocaine, and opioid use. The participant has been incarcerated over the past 32 years. He was recently paroled after completing eight years of a sixteen year sentence in the Illinois Department of Corrections for burglary and theft. The participant is on medications to treat HIV/AIDS and has been diagnosed with Major Depressive Disorder. He was referred to Healthcare Alternative Systems residential program through TASC as a condition of his probation.

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

The client met with his counselor on 05/06/2017 for his one on one session to discuss his treatment plan goals. the client has been on track with his goals and is working on his second step. the client discuss one of the things that his currently working on and that is acceptance. the client explained that he is having a hard time acceptance certain situations and things that happen in his life, and most of the time it result in him resulting to using drugs. the client as well talked about being disappointed in himself for relapsing after two years of being sober. the client reported that he didn't use the tools that were given to him from his last his was in the program, getting a sponsor and learning coping skills. the client reported that

will schedule an appointment to discuss and create a budget plan. Patient is currently free from all illicit drugs, which has helped her Adderall medication to be more beneficial. Primary Counselor will encourage Pt. to follow through with all mental health appointments. Counselor will prompt Pt. to develop a positive self-image. Pt. has denied having any auditory or visual hallucinations during the last quarter as evidenced by group and individual session notes. Pt. has had some setback in achieving her goals of decreasing her family conflicts and resolving intimate relationship issues. Counselor will encourage Pt. to attend the AMS parenting group and share her expectations regarding having a more functional family unit. During the next quarter therapy sessions, Counselor will utilize role-playing, role reversal, modeling, and behavioral rehearsal to assist Pt. in order to develop positive ways to resolve conflict with ex-husband. Pt.’s current treatment plan goals focus on opiate use disorder, financial, mental health services and parent-child relational problems. During the upcoming quarter, current goals will continue to be

Objectives/Progress: As the Pt. has participated in the AMS program since 8/24/16 and he has been able to maintain abstinence from all illicit drugs for 6 months straight t. Pt.'s UDS has shown no evidence of drug use or lapse/relapse. Pt. is currently in the action stage of change as indicated by reminding himself of how much progress he has made and ability to change his behavior and achieve goals during the past quarter. He has currently obtained a full-time job as a shelving installer. Patient reports as scheduled to receive maintenance medication services as instructed by AMS Doctor and attends all mandatory one therapy session once a month. He continues to share his understanding of being powerless and unmanageable over his addiction. During the next quarter sessions, Counselor will support a realistic view of change through small steps.

is currently working on establishing a healthy social support system. Pt. has been attending all AMS TX activities and dosing on a daily basis. Pt. has not yet begun to gain the knowledge of the assistances and organization that are available to him such as peer mentors, recovery coaching, self-help meetings, etc. Pt. doesn't attend any outside groups such as AA/NA meetings. Counselor will continue to encourage Pt. to get out into the community, discuss the activities he can become involved in and talk about the importance of not isolating for his recovery and from positive family members. During this upcoming session, Primary Counselor will assist Pt. to learn and identify ways to get help from supportive others at home, work, and in other settings. Pt. needs to find sponsor(s) and set of emergency numbers of supportive

Other services include a referral program for detox, followup counseling after base treatment has been concluded and a referral program for transitional or sober living housing. All of these services are provided by highly-trained counselors and clinicians who are highly motivated to help patients find a better way of

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.

Pt. has been in the AMS program for 2 years. Pt. has had no positive UDS results for two years. Pt. is on a dose of 150 of methadone and he is responding as expected to his prescribed medication. Pt. demonstrated responsible attitude by attending monthly AMS groups faithfully. Pt. has discontinued all illicit drugs use and now he has used financial income in a more self-sustaining manner. Pt is effectively addressing this area by making regular payments as scheduled. Demonstrates treatment maturity and appropriately participating in medical treatment services. Pt. was taught calming strategies, such as relaxation and breathing techniques as indicated by previous counselor documentation. Pt. was assigned to this writer caseload and counselor

Met with client for ISP review and to discuss treatment progress. Client appeared to be stable and engaged in the conversation. Client reported that she completed the FAFSA and is planning to go to Everette Community College in the summer. Client reported no use of substances. Client reported coping with temptation by walking away from the situations. Client was reminded that her relapse potential was moderate to high at this time and that she thus would be cautioned to avoid any unintended consequences; with help and support from treatment and her family, client would make his treatment a success. Reviewed ISP in Dim.5 dated 11/29/17, reported completion on approach C, but was unable to identify which peer pressure could be positive (approach

Problem # 5 Illicit opiate use Goal(s): to be free from illicit drugs. Status: Active Objectives/Progress: Pt. has struggled with continued use of illicit drugs (marijuana, opiates and amphetamines) and his last quarter UDS reflect a pattern of heavy substance use. Pt. was encouraged to work with the medical staff to achieve a stable dosing level. Pt. is regularly taking his medication as prescribed by AMS Doctor and he stated his current prescribed methadone 90 mg is working "well". During the last quarter, Pt. made progress on developing a therapeutic relationship with his new AMS counselor for the upcoming quarter. Also, Counselor focused therapy session on establishing rapport and building trust with him. Pt. is currently in the contemplation stage of change because he more open to receiving information about his negative habits and willing to use educational interventions which he agreed with this assessment. Pt. was reinforced for any statement that reflected acceptance of his chemical dependence and acknowledgment of the negative consequences that opiates has had on his life. During the upcoming quarter, Counselor will assist Pt. to discuss and weigh the pros and cons of continuing his addictive

D-The patient reports he is not stable at his current dose to the point he want to taper off. He expressed the need to want to get off on methadone. This writer listened to the patient vent about issues in his personal life and problematic issues with his transportation to ensure he dose daily. This writer then proceeded to discuss with the patient as to why he had entered treatment, his aspiration for his recovery process, and addressing alternatives to his barriers. The patient then reports he hasn't used any illicit drugs for three days, at which this writer commended the patient. When asked about what strategies to used to refrain from illicit drugs, he reports keeping himself busy and continue to care for his parents. The patient was

The role of a drug and alcohol counselor is to facilitate those suffering with substance abuse with exposure to 12 step recovery in group settings. In addition, a counselor’s role is to help engage clients in meaningful and therapeutic ways aiding in mental health recovery. It is my experience that many addicts and alcoholics are not only burdened with substance dependency, but with various types of trauma and mental illness. Recovery from both ailments is vital to the long term susses of those

In Counseling for Alcohol and Drug Abuse, the need to use different techniques is an integral part of the process. Working with an individual that is either entering into recovery or actively in recovery, the clinician must take their time with introducing the 12 Steps. The individual may not be open to the 12 Step philosophies at the onset. Addiction is very complex and actively affects the person on a daily basis; therefore, it is so important to start from the beginning of counseling to create a structured program.