My Life Change : John D.

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

The client arrived on time for his scheduled assessment. CPS caseworker Danita Brown referred the client test positive of illicit substance. The client is 30 years old African American male who is not married. He is the father of 3 children ages 1 month old 1, and 5 years old. He is currently in a relationship with two of the children mother. The client reports there was incident of family violence. The client reports his girlfriend was the one to assault him. Brent reports that he works at Sam Clubs in Pearland and has for the last 3 years. Brent reports three years of colleges. The client reports growing up with his parents, however they divorce later, but they both are supportive. Brent denies any medical or mental health concerns. 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

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.

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.

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

Mr. Pearson’s drinking began when he was 15 years old attempting to escape the violence and ridicule in his home. By the time Mr. Pearson was 16 years old, he was drinking several 40 ounce beers daily and smoking marijuana. His drug use escalated and he began using cocaine at 19 years of age and crack cocaine at 25 years of age.

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 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

Data: Client came to appointment on time with a decent attitude, and engaging during session. Today’s individual session was focused on addressing client’s treatment attendance issue. Client has not attending treatment group consistently, which will put her not in compliance with Kaiser Permanente suboxone program, as well as CD treatment at THS. Client has 7 absences from 03/01/17 – 05/25/17. Client reported no use of alcohol or other substances since started treatment. Client reported going to Kaiser Permanente weekly for counseling, UA, and obtain Suboxone prescription at Capitol Hill, Seattle. PC provided client with information for different OP groups but client stated, “I will make it work. Wednesday group works for me better.”

Substance Use History: The patient denies any drug or substance use except for Alcohol and Marijuana; started using in high school and everyday use.

Client has no know history of previous treatments. Client desires treatment due to unhappiness with current life style. Client states that his longest abstinence from alcohol is 4 days, nicotine an hour, and marijuana and cocaine 1-2 years over the last 5 years. Client recognizes several triggers for drinking episodes (social anxiety, loneliness, fear, feelings of inadequacy, and guilt). Client is not experiencing any cravings for chemicals at this time (currently using nicotine). Client states he has current problems with family resentments and anger, self-esteem, and anxiety that are unresolved. At this time, potential for relapse is moderate to severe. Client a limited support network and no relapse prevention plan.

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.

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