1. No signs or symptoms of intoxication or withdrawal were present while in treatment. Current status is unknown.
Risk Rating: 0
ASAM LOC: 0
2. No biomedical signs or symptoms were present while in treatment. Current status is unknown. Client is recommended to obtain a complete physical exam to rule out any medical issues that may interfere to complete treatment successfully.
Risk Rating: 0
ASAM LOC: 0
3. Client continues to demonstrate unstable behavior within the treatment as evidenced by multiple jail sanctions while in IOP treatment, and arrested on suspicion of DUI on 08/29/2017 as result of continued alcohol use. Treatment in a higher level of care is indicated as evidenced by lack of ability to control his impulses to use alcohol and/or other mood-altering substances despite negative consequences.
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Although client completed Intensive Outpatient treatment and increased awareness about negative impact of substance(s) use, client has not yet implemented recommended changes, and will need to increase the degree of readiness to change, which can be addressed at Level 3.1 inpatient treatment services.
Risk Rating: 3
ASAM LOC:3.1
5. Client is at a high risk for relapse as evidenced by his continued alcohol use. Client appears to be unable to maintain sobriety on his own and has little recognition and understanding of alcohol and substance use relapse issues. Client appears to have poor skills to cope with and interrupt addiction problems, or to avoid or limit relapse. Client would benefit from an inpatient treatment to target problem
PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.
Xavier then reported, the applicant recovery is up and down and the reason the patient was transferred and admitted to the Norwich location was due to an altercation as the Hartford Dispensary has zero tolerance for physical violence. Since May of of this year, the applicant's UDS results are negative. Last positive result was in April for cocaine, according to the counselor. Please note, during the applicant intake, he was asked about other illicit drugs and only confirmed for use of heroin and THC, not the cocaine. The applicant's current dose at the Hartford Dispensary is 105mgs as he is being detoxed daily. His highest dose was at 145 mgs before his detoxification. The physical altercation was the applicant's first behavioral incident at the clinic. He was also on a 90 Probation for his illicit use and it would have expired in August, but due to the recent incident, he was removed from the clinic, not discharged, but transferred as mentioned before. Counselor Xavier only concern of the applicant is maintaining his
No signs or symptoms of intoxication or withdrawalwas reported at time of discharged. Client reported no urges or cravings at time of discharge.
PO had no service plan open in this dimension due to participating only one week in treatment. PO reported that he is living with his fiancé and her children at this time. PO reported he is not working due to working increased a level of stress and anxiety into his daily life. PO reported attending AA meeting and communicating with his sponsor regularly. PO will benefit from building and utilizing positive
The client has maked progress, but has not yet achieved the goals articulated in the individual ized treatment plan, The client is currently working on identifying the root cause of his addiction along with identifying his traps and triggers that would result in relapsing. Contiuned treatment at the present level of care is assissed as necessary to permit the client to contiune to work towards this treatment goals
The reading entitled “The Treatment Plan” focuses on developing treatment plans, particularly for those in substance abuse rehabilitation programs. First, the interdisciplinary team, which consists of a variety of professionals such as doctors, nurses, and therapists, writes a summary of the client at intake to determine the problems, how they came about, and the potential solutions. Next, a problem list is created. The problem statement is one sentence explaining the problem, which is abstract and not tangible. Therefore, signs and symptoms are also listed underneath, such as history of DUI and the blood alcohol level. These are used as evidence to back-up the problem statement. After, for each problem statement, several goals are listed that
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
Client reported alcohol as his drug of choice with the last use date of March, 2017. No acute intoxication or withdrawal symptoms were reported. No treatment plan was developed in this dimension. Client appears to be stable at this time.
She reports a history of back pain, ovarian cysts excision, and breast tumor. She denies chest pain, shortness of breath, or palpitations. Patient reports that her immunizations and preventive care are up to
Although the main goal of the assessment is to refer clients to treatment, many clients refuse treatment. However, they are willing to accept referrals to non-addiction agencies to resolve problems that have either been caused by addiction or that led to the problems. This assessment may be an intervention that the client needs. You will want to use the appropriate research-based screening tools that may be applicable to the client’s individual circumstances.
Client presented staff with a challenge when asked to work on today’s assignment because he believed none of the relapse warning signs applied to him, and he claimed could give a reason why for each of the 53 signs. It was pointed out that he must have relapsed since he is in a DUI II program and was asked about the circumstances that led up to this occurring. After hearing a quite lengthy and convoluted response, he inadvertently revealed that he actually had at least several relapse warning signs including I resent the people closest to me, I don’t believe I’ll ever have fun sober, and perhaps most salient, I am overconfident in my recovery. Subsequently, however, he did not admit these things directly, and did not actively fill out anything on the relapse worksheet and presents with the attitude that since he has a sponsor, goes to meetings, and feels he no longer wants a life that is riddled with consequences due to his drinking, that “he’s got this.” After being given a caveat about complacency, client did fill out a separate worksheet and listed 10 positive people, places, or things, and seemed to have an authentic grasp on what these should look like. Interestingly, he did choose to list “Think I can do this” in the Negative column, possibly showing some recognition of the lurking dangers of
Jed, a 38 – year old welder, enrolled in the treatment center after his arrest resulting from drunken driving (DUI/DWI) (National Institute on Alcohol Abuse and Alcoholism, n.d.). His lawyer has advised him to stop drinking and get treatment until his trial date, which is in approximate two months. Jed does not believe that he will serve any jail time, but feels that treatment could help strengthen his court case (National Institute on Alcohol Abuse and Alcoholism, n.d.). In this paper, I will create a relapse prevention plan that will aid Jed as he enters into his treatment program. This paper will also show
A client admits to alcohol dependency on a consistant and regular basis because the loss of job. The client exhibits hopelessness and depression. The client has explained they experiencing insomnia, and decreased energy to do anything. This explains their poor personal hygiene. As the clinician the safety of the client is of the utmost importance.
ABSTRACT: Information Technology General Controls (ITGCs), a fundamental category of internal controls, provide an overall foundation for reliance on any information produced by a system. Since the relation between ITGCs and the information produced by an organization’s various application programs is indirect, understanding how ITGCs interact and affect an auditor’s risk assessment is often challenging for students. This case helps students assess overall ITGC risk within an organization’s information systems. Students identify
FFC is a publicly traded, regional grocery store chain located throughout mid-Atlantic region; heavily relying on an integrated suite of application programs to manage its information. A new fingerprint bio-coding payment system was implemented by FFC to further its competitive edge. Such complex and sophisticated system requires FFC to change several of its ledger application programs, with particular emphasis on cash receipts processing. Therefore, the ITGC review is necessary.