Homicidal Ideation

Mr. Davis is a 33 year old male who presented to the ED with homicidal ideation with a plan. Mr. Davis states he has a plan to go out in his yard with a machete and kill someone. Per documentation he states, "I'm going out into the yard with my machete and I am afraid I am going to kill someone. I feel really crazy." He states he has these thoughts towards anyone that does him wrong. At the time of the assessment Mr. Davis is asleep, however becomes awaken and 4x oriented by hearing his name called. He has a history of Bipolar. He denies current suicidal ideation, homicidal ideation, and visual hallucinations. He does endorse auditory hallucination. Mr. Davis reports hearing several people telling him things. He reports his outpatient provider is DayMark and he usually go there twice a month for his Depakote injections, however has not been there since

3. The patient had informed this writer initially of his goals of wanting to return back to the Hartford Dispensary due to the length of time he has been with the clinic and his positive rapport with his prior counselor at the other facility. The patient was compliant with his individual sessions with this writer and provided cancellation if unable to attend the session in the meantime while he awaits on the process of completion with his intake at Hartford Dispensary.

D-This writer met with the patient as he was placed on HOLD to address the status of the IOP. The patient provided this writer a paper that was provided to him with listing of IOP for him to explore. The paper shows scribbles of the patient taking down notes about his attempts of who he called. The patient reports Connecticut Addiction Recovery will call him back within 24-48 hours. The patient was able to schedule an appointment with New Direction for May 20th at 7pm; patient spoke with Dan. This writer commends the patient for all of his efforts; however, the patient needs to schedule something earlier than May 20th. This writer asked the patient about ICRC-Coventry House. According to the patient, he called the contact number and showed proof. The patient reports that ICRC gave him two different number and told him to do a walk-in at 8:30am. This writer shared with the patient about a recent conversation this writer had with ICRC. This writer told the patient

On 7/11/2015, CM did a visual and had client come to the social service office. CM completed Bi-Weekly ILP Review. In the meeting client appears to be wear out, and tired. She was constantly throbbing her forehead, like if she was having headache. CM inquires what the problem is. Client replies “she doesn’t like the shelter food and sometimes she doesn’t eat” CM advised the client to eat and nourished her body. CM also observed that client is depressed but she continues to refuse medical referral to see a psychiatrist and medical doctor. Client continues to mention her son who is in foster care, and the physical altercation she sustained many months ago here at this shelter. CM mentioned to the client she was a transferred from another shelter due to physical altercation, CM continues to relate to the client she

This writer agreed to meet with the patient as she missed group and her scheduled individual session with this writer. The patient apologized to this writer for her absence and then reports about transportation issue. This writer discussed with the patient about her MVA this month on the 18th and the status of obtaining a police report. The patient reports, " I can get the police report by the next appointment. I just have to go to my insurance company that isn't too far from where I live to get a copy of it."

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.

D-Met with the patient as she placed on HOLD due to recent concern of her overall well-being reported by Nurse Frank as he reported to this writer yesterday of his concerns that the patient's boyfriend is refusing her to increase on her methadone due to an agreement and the patient tends to appear emotional. Upon meeting with the patient, the patient immediately knew why she is meeting with her and started to get emotional. Denies feeling SI/HI. According to the patient, she had an agreement with her boyfriend of which she agreed to increase her dose up to 55mgs as her boyfriend will closely monitor her recovery. The patient does not feel unsafe around her boyfriend as she reported. This writer strongly advised the patient that she has rights to her own recovery process because it's her in the recovery and seeking treatment, at which the patient agreed. But says, "I am fine with my current

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).

Pt. called this writer to report that he no longer wanted to be in the program. Pt. asked if he needs to sign a Voluntary Request for Termination. Pt. reported that he is going to stop by the clinic to pay his tx services fees. Pt. stated, "I am done wit methadone. I'll go there tomorrow and pay my bill in full." Counselor told that he needs to talk to the head nurse and to sign the AMA Detoxification Agreement tomorrow, Saturday 2/25/17. After discussing this issue with him, he still insisted that he did not want to be in the program and he wants to sign the AMA Detoxification Agreement

Client appears to be decompensating. She is losing weight and she was refer to take a urine test to rule out toxicology. CM assessed client needs: client must maintain PA case active, client must meet with CM every Friday and the Client must maintain all off-site medical appointments and medication regiment. CM reviewed Bi-Weekly ILP. Client agreed and

Wife reported his multiple providers shared their notes. Mrs. Overman reports 4 year ago when his father died, Mr Overman became depressed and started to abuse opiate and other pain pills. She reports his PCP as recommended him to attend substance abuse treatment. He is not currently attending any outpatient services for substance abuse. Mrs. Overman states out of the 15 year she has known him he has not attempted to harm himself. She reports At the time of the assessment Mr. Overman currently denies suicidal ideation, homicidal ideation, and symptoms of psychosis. He denies any mental health history or attempts to harm himself. He reports attending substance abuse treatment at 2X Bethal Colony. He reports yesterday his friends gave him something to take for his pain. Mr. Overman reports going to Walmart with all his medication and his

Client was scheduled for a Mental Health Assessment at Woodhull Hospital on 8/9/2016. Client reported she didn’t go because she doesn’t need. Client continues to report if the Mental Health Counselor at Woodhull Hospital need to contact her and tell her why she need to be seeing and to show documents. CM explain to the client since she saw the onsite psychiatrist doctor, that the doctor referred her for mental health counseling. Client agreed and another appointment is scheduled for

This consumer is a 48 y/o African American male diagnosis with bipolar I. The consumer is sorry about having thought of killing himself. The consumer does have insight that he know that his behavior is because he has not been taking his medication. The consumer took a cab to the hospital because he was having suicidal thought and his plan was to jump off the porch. The consumer states that he had two frozen blue drink on Wednesday at Chene Park. The consumer report that he was not feeling well and starting having a break down and wanted to get away. The consumer states he has not been sleeping since he has not been taking his

The writer met with the consumer today and reschedule his intake appointment at Detroit Central City. The consumer intake appointment is schedule for Tuesday, 4/11/17 at 10:00am. This is the consumer third appointment for intake at Detroit Central City the writer explain to the consumer the importance of keeping his appointment. The consumer report that he will make sure he stay at the transitional house on Tuesday morning so he could go to his appointment. The consumer was also irritated about the him not having a drying towel at the house and he states that he has not taken a shower since he has been at the home and he is also complaining about the staff and the food. The writer explain to the consumer that we do not have any control over

he writer was able to complete Mobile Crisis Stabilization Intake Assessment. The consumer report that she has an appointment to see the doctor at ACC on 10/6/16 at 10:00am. The consumer is compliance with taking her medication. The consumer is preoccupied with getting a cigarette and getting her own apartment. The consumer is in compliance with her treatment but would like to find a day program to attend. The writer told the consumer to discuss with her case manager or therapist about a day