Reflective Summation Paper

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

Mental health: Client reported that he is currently waiting for an appointment for MH services from his OTP. The client reported his intention to continue attending a PTSD support group while in the program. Client denied having any S/I and H/I at this time.

On 6/30/2016, CM met with the client to complete to Bi-Weekly ILP Review. In the meeting, client was dressed appropriately for the weather. She was very loquacious and client. Client appears to have difficulty sustaining attention, client does not seem to listen when spoken to directly and she is unable to follow through on tasks. Client affect is inappropriate and she denied suicidal or homicidal ideation.

D- This writer met with the patient about his request for a change of counselor. According to the patient, he reported that his assigned counselor, Cherron does not make himself available for schedule appointment or even at the exact time of the appointment as the patient tends to wait for a quite some time. In the beginning, as per patient, his assigned counselor was punctual but everything has changed since the patient made a compliant against the counselor for not informing the patient about the need to validate his Rx Scripts and the severity of the matter to avoid entering a detox treatment. Since then, the patient feels that his relationship with his counselor has changed and feels that Cherron tactics appeared to be vengenaceful whereas

D-The patient arrived to the clinic emotional and was advised to see this writer. According to the patient, she's upset about her DCF case, her supervised visit with her son that hasn't occurred yet, loss of employment, and owing $80. 00 for her rent. This writer provided support, validated the patient feelings, and encourages the patient to maintain contact with her attorney and to also, contact 211 for financial assistance. In addition, reach out to the court system to address the violation to her supervised visit as it is not being honored. During the remainder of the session, the patient provided an updated on her mental health provider whereas she is no longer going to Wheeler Clinic due to the travel distance. The patient signed an ROI

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

CM was out on vacation from 5/3/2017 to 6/14/2017. On 6/20/2017, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed in proper attire for the weather. Her affect and mood was appropriate. Client maintains eyes contact appropriately and she was oriented to person, place, time and situation. Client continue to deny suicidal or homicidal ideation

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.

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.”

During the time of assessment the patient was sitting upright in her bed, her father at her bedside. The patient denies HI, SI, and symptoms of psychosis. The patient reports a history of depression. She expresses that a few days ago her and her boyfriend ended their one year relationship and he left the home due to the multiple domestic violence situations that have occurred in the home. The father of the patient provided a copy of the message sent of Facebook sent to the boyfriend, which expresses that the patient is hurt by the relationship ending and has suicidal thoughts with a plan to take a prescribe bottle of Valium to cope with the situation. Per documentation, patient's boyfriend throws knives at her, beat her and is verbally abusive. This was confirmed by the patient and her father. Per documentation the patient's parents picked her up a few days ago and she feels safe to go home. The patient reports joking about taking pills on Facebook. Per documentation the patient states, " If I wanted to kill myself,I'd just stay with him." Further the patient states, "If I go back to my boyfriend, he's going to beat me and I won't be able to take in much long." Per documentation the patient express crying episodes and feeling sadness, panic attacks for the past few day, and trouble

Counselor met with Pt. for his monthly individual session. Counselor and Pt. discussed his progress in treatment, any medication issue, any triggers and acceptance of his TX plan. Pt. signed his Record Service sheet. Pt. indicated that he does not attend the clinic Tuesday, Saturday and Sunday and he likes having more time in his schedule because he likes to take care of his business and different errands. Pt. verbalized how hard it is to stay away from his business because worried about his employees and clients. Pt. stated, “The business is like my kid,” Pt. spoke about how he is thinking about opening a second shop around this area. Pt. commented that he isn’t experiencing serious side effects and prescribed medication is working well. Pt. informed this

The client meet with a substitute counselor for his 1x1 session to discuss how are things going and to assist the client if he had any question about hie recovery. the client has been in compliance with the program rules and regulations. the client has been participating in group process sharing his character defaults with other member of the group. The client has no trouble with being open about what he needs to work on as an individual and will asks for help if needed. The client at this time is working on learning how to have a healthy relationship with people in general. The client seems to understand the importance of communicating his needs and listening to the needs of others. The client counselor will meet with him next week to

Primary Counselor met with Pt. for his one hour monthly individual session. Pt. showed up late to this session. Counselor greeted him and asked him how he has been since last session. Pt. reported to be busy at work and he requested to reschedule this therapy session for tomorrow, 1/31/17. Counselor discussed why therapy is important for his recovery and encouraged him to don’t reschedule the session for tomorrow when he can do it today. Counselor stated, “Counseling is one of the keys to reaching his goals.” Pt. agreed to stay for the session, but this writer encouraged him to receive his dose of methadone before starting the session. After 5 minutes, Pt. returned to the office and agreed to sign his Record of Services sheet. Pt. stated that

the client met with his counselor for his 1x1 session to discuss his progress in the program and regarding his treatment plan. Client has shown a lot progress sine he has been in the program. However the has been 13 other program so, the client could be telling the counselor what she wants to hear. on the other hand the client has can to his counselor and reported that he had an doctor appointment on 2/03/2017 for bur his was canceled. the really show some growth. The client also made up own treatment plan an area that he needs to work on . but the thing that is wrong with this is client is not focusing on humoring his self or even thing about learning to applying what he has learn to his life. CADC-1 Yolanda Smith

years old and feels responsible for it. Since the death of his aunt, he has irrational fear of abandonment and being alone. Since this incident, the client has been