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Hcr/275 Week 5 Case Study In Substance Abuse

Decent Essays

There are several pieces of documentation that were used in the case. They include guidelines for continued treatment with the agency, consent forms, comprehensive assessment, and a performance evaluation tool to measure the effectiveness of the interventions. First is the program rules (appendix A). The program rules include proper conduct while at the out-patient facility, and expected adherence to treatment. Examples of proper conduct are no smoking except in designated areas, and having shoes and shirt on while on site. Other examples involve behavior on premises, which include any act of violence or threats of violence to people or property, carrying a weapon of any kind into the site, and any selling or purchase of illegal drug or any …show more content…

The form allows the client's guardians to decide what information will be released and they can also determine the purpose of the disclosure. For example, information that could be released is treatment plan, psychiatric evaluation, and standard treatment. An example for purpose of the disclosure is coordination of services and of care. The document allows the the client's guardians the flexibility to choose what information is divulged and the limitations of what information is provided with another entity involved with the treatment of care. An example of when the document is important is when coordinating treatment and implementing treatment with the school. In the client's case she is currently struggling with passing the third grade. The guardians of the client can utilize the consent for disclosure of confidential information to communicate to the agency what information if any they want disclosed regarding the …show more content…

The assessment holistic approach to understanding what has occurred and currently occurring in the clients life as well as understanding what is considered a priority of treatment for them and their guardian. The assessment begins with the presenting issues asking what brought the client in. The section also covers when the problem started, how long it has been going on, what is the level of intensity of the problems, and how frequently do they occur. In the family and social history section examples of questions asked are current household member, how does the client get along with others, client's strengths, and who do they go to when they need help. The next section is the abuse and sexual risk behavior where the client is asked if they feel safe inside and or outside there home and if they have or know of anyone that has been abused or neglected. Developmental history is then taken, which includes history of pregnancy, any disorder or disabilities the client has been diagnosed with, and delays in any motor

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