My Life Change : John D.

SOCIAL HISTORY: Patient admits alcohol ingestion nightly and on weekends. Denies tobacco use and illicit drug us. He is married.

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 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

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

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

Mr. Goins is a 52 year old male who presented to the ED via LEO following a 4 day binge on alcohol and requesting help with his dependence. Mr. Goins reports he moved to Asheboro recently and found work, however recently lost his job. He reported a history of alcohol use and depression. Dr. Keith requested an assessment on Mr. Goins.At the time of the assessment Mr. Goins denies suicidal ideation, homicidal ideation, and symptoms of psychosis. He reports 5 days ago he became unemployed. Mr. Goins reports his fiance who is his primary support system left town to go to a doctor appointment in their home state of Georgia. He reports binge drinking for the past 4 days attempting to cope with his recent stressor. Mr. Goins reports calling his fiance last night an expressed to her he need help. He states, "I told her I felt at the time no reason to live." Further Mr. Goins stated, "I just had too much in me last night, I had about 14 of them airplane bottles." Mr. Goins denies a history of self harm. He does report a prior hospitalization for depression in Georgia. He also reports a history of attending substance abuse treatment, which was a positive experience for him.

Pt. has been in the program for over 3 years and she is currently in Phase 0. Pt. has participated in the AMS of De methadone clinic, she has been able to achieve abstinence from illicit drugs but she is failing to comply with the mandatory counseling sessions. Pt. is now eligible to receive phase 1 take home privileges if she maintains satisfactory attendance and scheduled appointments. Pt. identified her children as a motivational factor to change and to reinforce the importance of remaining in recovery. Pt. was advised to obtain a sponsor and attend 12 Step meetings. Pt. has done in achieving her goal of maintaining financial compliance despite the holiday financial stress. Pt. seemed to accumulate a back balance, but normally pays for late account balance in full upon notice of an administrative taper.

Problem #5 Illicit opiate use Goal(s): To become drug free Status: Active Objectives/Progress: Pt. has not done well in achieving his goal of maintaining abstinence from all illicit substance use over the last quarter as evidenced by his positive UDS. Patient’s last urine screen results indicate that opiates have been used. Pt. reported that he was able to be clean from more than 30 days but he used drugs while walking through his neighborhood. Counselor expressed concern and disappointment about his recent relapse on heroin. During last month session, Pt. recognized the danger of the situation and how he will avoid the acquaintance that offered him drug. Pt. has failed to move to Phase 1 of the AMS of DE TX program due to his four positive UDS since entering the program on 7/6/16.Counselor will meet with Pt. to examine pt.'s motivation to stay clean, how to deal with triggers in order to achieve continued abstinence, to help him recover from his recent relapse and reenter the change process.

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.

The client has high motivation for treatment within MRFH. The client was diagnosed with Alcohol Use Disorder: Severe and Cocaine Use Disorder (crack): Moderate. The client sought treatment at MRFH when he realized he had lost control of using alcohol and crack cocaine. The client stated he attended the MRFH program in the 1980 's but does not remember the exact date of attendance. The client stated he was diagnosed with Mild Depression by a primary care physician when he was 56-years-old. The client reports he has no history of suicidal or homicidal attempts, and currently denies having any suicidal ideations or homicidal ideations. The client stated one to two times per week he experiences muscle tension and worrying about things that he often realizes have no significance. The client stated prior to the age of 18-years-old, "I would knock over my neighbors mailboxes and destroy their gardens, because they would make my parents aware of my wrong doings and that was way of getting them back." The client stated, there was one time that I started a fire and blamed it on my brother. I would break things as well and blame someone else. The client stated if there was an event taking place that he wanted to participate in, he would rush and complete what he was doing so he could become involved in other events taking place around him. The client stated, "I started using drugs and alcohol without thinking about what the consequences. The client appeared to be oriented to the

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

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

CPI arrived at the family residence located at 149 S Calhoun Avenue, Eatonville, FL 32751. CPI completed a joint visit with Taina L. Ramos FIS Counselor. Taina completed a BHC screen with Mr. Clayborne. Mr. Clayborne admitted to have a history of alcohol misuse and impulsive and aggressive behavior while under the influence. He began drinking while in his 20’s and drinks 1 to 2 times weekly. Mr. Clayborne drink preference is beer, but sometimes drinks vodka. He usually drinks when is stressed out. He has been to Alcoholics Anonymous meetings in Springfield, MA. The last meetings he attended was about 2 years ago. While in prison was seen by a psychiatric five times a day for 3 months, but is it not diagnosed with a mental health condition.

Objectives/Progress: Pt. has maintained Phase 7 take-home privileges. As the pt. has participated in a total recovery program, he has been able to maintain abstinence from mood-altering drug use as evidenced by submitting 19 clean UDS results since entering and reporting sustained abstinence. Pt. is compliant with all aspects of treatment, provides negative UDS, and attends required monthly counseling. Pt.'s program attendance is in a good standing but pt. needs to attend different AMS groups. He was advised to schedule different groups and the benefits of doing so. Pt. has achieved a lengthy period of sobriety and has good insight into personal recovery behaviors. Counselor will review this long-term goal with pt. during his therapy sessions.

MR has unlimited access to group and individual counseling at New Beginnings. It was recommended MR visit a psychiatrist to be assessed for medication. MR does not believe he needs to be on medication, however resources were still given. MR would benefit from medication immensely. He would be able to think clearer and communicate better. It was also recommended MR attend Narcotics Anonymous (NA) meetings daily. After a group session at New Beginnings, all of the clients attended an NA meeting. MR stayed in at the NA meeting for two minutes and then went home. MR does not want to attend NA meetings because he believes he is getting enough help at New Beginnings. It would benefit MR to hear others stories about how drug use affected