I Collected Rhonda 's Demographic And Intake Information

A clinical assessment is then conducted for treatment needs. Different treatment plans are made for each client. Individualized treatment plans are used to make referrals and they are updated periodically.”

Before our session is to begin I need to make you aware of the privacy and confidentiality policy of the community center. HIPPA is a law enacted in 1996, to provide privacy standards to safeguard the client or potential client’s medical records and any healthcare information (HHS.gov). Here you have acknowledged you understand the HIPPA law. As a counselor I must follow a code of ethics as outline in the ACA 2104 Code of Ethic, it covers five ethical principles I must abide by respect for Autonomy(clients right to choose their own direction), non-maleficence(do no harm), beneficence ( to do good), justice( act in fair manner) and fidelity (client interest above the counselors) (ACAcounseling.org,2014).

The patient expressed about feeling that she is self-sabatoge her recovery for no apparent reason and currently thinking about going into an inpatient treatment- more so, a treatment that is spiritual. The patient shared that lately she's been feeling down and haven't been to going to church for the past two weeks. In addition, the patient shared about having homocidial thoughts with regards to her daughter's DCF case as she expressed frustration with the custody battle. This writer advises the patient about this writer's role as a mandated reporter and based on the patient comment of having homocidal thoughts, she recanted her statement and says," So, you are telling me that I cannot vent and express how I feel.....I am going to keep my mouth

MT has build rapport with the client to help him with stress management strategies and coping skills. The client is currently staying with another family member for the summer and through this change of environment has allow the client to accept the treatment and work on bettering himself as the client has had no behavior incident since being discharge from Dover Behavioral Health to his other family member house. The client’s MT will continue to provide the client resources to help him control his emotion and express himself to others, which would provide help when he moves back with his guardian. In addition, the MT will assist the client’s guardian in improving communication with

Counselor met with Pt. for his monthly therapy session. In this session, Pt. discussed his recovery progress, new tx plan and his assignment on Relapse Prevention. Client was upset about not moving on 4/12/12. He asked writer if he was moving forward this week, and writer shared with the Pt. that he needs to keep improving and leave the take home privileges up to staff. Pt shared with writer his Comprehensive relapse prevention plan. Pt. processed roadblocks and barriers that interrupt his recovery plan. He said having cravings t the moment is one of the problems. Pt. reported that he is currently receiving 60 mg of methadone and he thinking about going up. Pt. denied having any mental health issues and no suicidal ideations. Counselor helped Pt. to

The client was referred to therapy services as part of the standard residential treatment at the group home. The precipitating events that led to her having to attend therapy at residential treatment was that she received a 7 day notice of removal from her previous foster home due to increased runaway behaviors.

The client has every right to choose whether or not they receive the treatment that they are recommended by a counselor. By providing the client with any information that can contribute to them making an informed decision on their treatment plan, we can be sure that we have

As a counselor, there are certain guidelines that we must follow as it relate to the treatment of a client. Research states that “Informed consent is an ongoing part of the counseling process, and counselors appropriately document discussions of informed consent throughout the counseling relationship” (ACA, 2014, p.4). This guideline is crucial to the well-being of the client, because it allows the client to decide if they want to continue this client-counselor relationship. It also, exhibits that the counselor is in compliance with all federal state laws to protect themselves and their practice. Most clients who choose to participate in counseling have never participated however, it is important to provide an overview of

In this paper I will discuss the session of Dr. Buckley along with his clients Aaron, Robyn and Michelle. SOAP is one of the notes that are used during a client treatment process. SOAP acronym stands for subjective, objective, assessment and plan (Laureate Education, Inc). Subjective information is the clients problems and what is going on. Objective information are the different mood, the effects and the behaviors that are shown in counseling. Assessment information is when the counselor is trying to get a understanding the concern of the client. Plan is what the future treatment is going to be for the client. Quinn and Gordon (2003) suggest that the major advantage of the SOAP documentation format is it's widespread adoption, leading to general familiarity with the concept within the field of healthcare.

I received signed consent for services from her assigned Specialist with the New York Department of Child Safety. I informed Precious and her assigned Specialist that my notes from our counseling sessions would be confidential and shared with no one. I informed Precious that progress or lack of progress would be shared with her assigned Specialist. Precious was reluctant at first but soon cooperated in providing information for the assessment intake. It was determined Precious would participate in weekly counseling.

Patient is a 30-year-old Caucasian Female who presents to CRU 2 via ambo from PRC West. She is on ACOT for non-compliance with her court order terms and outpatient treatment plan. Partners In Recovery is her OP treatment agency. Heather is currently homeless, and on SSD income. She is alert and oriented 4x and cooperative with intake assessment. She reported that she has been taking Ativan and Klonopin, she insisted that I call the provider for those orders. She denies DTO/DTS, vital signs WNL's. She will benefit from meeting a provider to discuss med stabilization and therapy.

The writer accompanied the consumer to her intake appointment at Northeast Guidance Center. The consumer came to the appointment in the clothes she slept in and did not wash her face or shower. The consumer was defensive during the intake appointment with one of the therapist. The consumer would not speak up and often time would have the therapist repeat the questions. The writer spoke to the consumer about her behavior and explain that it is necessary for them to asks questions because they want to make sure she get the best services possible. The consumer did aplolize for her behavior. The consumer next appointment is on 8/11/16 at

The primary therapist of the client contacted the client's parent over the phone to introduce himself as a primary therapist and make the first appointment for the first conjoint session. The client's mother agreed to meet with the therapist and the client over the phone for the first conjoint session on Monday, July 24th, 2017, at 04:00 pm. The mother checked with the therapist about the client as she reported that this is the first time he leave the house for a long time and she was anxious about his mood as she stated that he was depressed when he left the house.

Privileged communications are defined as “an exchange of information between two individuals in a confidential relationship” (“Privileged communication,” 2008). There are 5 generally accepted types of privileged communications: attorney/client, doctor/patient, psychotherapist/patient, parishioner/clergy and marital. This week’s unit focuses mainly on the psychotherapy/patient relationship. One of the main reasons this privilege exists is to allow a person seeking treatment to be completely honest with the psychotherapist without fear that the information they divulge will be shared with family, friends or the public in general. This allows for the therapist to have as complete a picture as possible of the patient to assist in the development

A clear, well-organized record-keeping system is essential for counselor who provides treatment, nutritional assessment and consultation services. But setting up such systems can be challenging. For one, a counselor need to attack the fine balance between the need to maintain client privacy and confidentiality and the need to communicate with insurers, other treating professionals and larger health systems. Counselor’s records must also follow the state and federal laws (King & Klawitter, 2007). . In addition, a counselor needs to plan for retirement and the eventual disposal of records. In order for counselor to have these records, information needs to be documented. Some of the things that need to be documented include counseling