Summary: Bi-Weekly ILP Review

Client stated that she first started using alcohol at the age of 14. Client reported most recently consuming alcohol within the past 2 days of this assessment. Client reports out of the last 90 days prior to her evaluation, she used alcohol on 70 of those days, 45 of those days she drank herself into intoxication. Client reported over the past 2-12 months, she has had repeated

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.

Client is a possible 2010E, CM will update client psychosocial evaluation and re-submit housing package to PACT. Psychosocial will be initiated on 8/6/2015.

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

At 0824 this clinician met with the patient who reports her weekend was not unpleasant. She reports she is continuing to have problems locating housing. She reports her family members continue to refuse to allow her to live with them specifically her father and her uncle. She reports she has one friend who is considering allotting her the capability to reside with her under the condition that she speak with her Child Protective Services (CPS) caseworker first. She reports she does not want to reside in a homeless shelter with her son as she has done this before and the experience was not up to her standards.

The writer help the consumer to complete intake paperwork at Northeast Guidance Center the consumer is a DD and does have problem with reading, and writing. The consumer report during his assessment that he would like to have income, go back to WCCC and have a place of his own. The consumer also states that his mother was murdered when he was young and he live with his aunt whom he call mom and his cousin who often time treat him mean. The consumer is also unable to get around catching the bus because he does have problem reading. The consumer next appointment for his treatment plan is schedule on 01/03/16 at 9:00am. The consumer health insurance has expired so he is unable to get transportation to his appointment. The writer will assist the

Meeting is arranged for Tuesday, September 20, 2016. Client continues to report not even her coordinator she gave him a copy of her psychosocial and psychiatric evaluation. She also mentions that her coordinator is requesting for client to be removed from his

On 8/7/2015, CM met with the client and completed Bi-Weekly ILP Review. Client arrived early for the meeting; she was alert, satisfactorily groomed, and casually dressed. In the meeting she was cooperative and friendly. CM inquires how client is doing since the last Bi-Weekly ILP Review. Client reported she is exhausted from running around obtaining relevant documents to be submitted to Lemle & Wolfe, Inc. by 8/3/2015. She continues to reports she has Straight Medicaid and she is searching for a Managed Cared that cover oxygen tanks.

I-CM informed the client that he had contacted and left a message with LA Family Housing the week prior, but no one answered due to the Thanksgiving holiday. CM contacted LA Family Housing again with the client present, but on one answered and a voice message was left. CM continued to assess client’s mental health and medication compliance. CM inquired what outside activities the client has been engaging in. CM inquired about client’s plans for Thanksgiving.

Throughout the session the client was able to give me a timeline of his substance use. He kept looking down on the table. The client showed strength by recollecting his substance use history and his behavioral problems.

She remember enjoying the experience but reports continued experimentation with drugs two or three times per month until college there she stopped drinking following a binge-drinking episode prior to leaving for college in which she reports drinking until she passed out. Following this incident, she reported finding drinking sickening. Then drugs came into play. She now reports using drugs primarily on occasions, along with alcohol. Last use was two months ago, one glass of wine at a holiday party. No current abuse or dependency on drugs and alcohol. Client reports experimentation with weed in high school when her parents divorced. She did not like the taste or smell and reports it made her sick, so she did not continue. Client reports regular use of pain killers, up to six pills per

Client appears to be decompensating. She is losing weight and she was refer to take a urine test to rule out toxicology. CM assessed client needs: client must maintain PA case active, client must meet with CM every Friday and the Client must maintain all off-site medical appointments and medication regiment. CM reviewed Bi-Weekly ILP. Client agreed and

On 7/15/2015, CM conducted a search via Security to locate client. Client was found sitting in the patio. Security asked the client to go upstairs to the 3rd floor to see social services. CM met with the client and completed Bi-Weekly ILP Review. In the meeting the client was well groomed and dressed appropriately for the weather. She appears to be calm, cooperative and friendly. CM inquires how client is doing since the last Bi-Weekly IlP. Client replies she is doing well and she is still waiting for DHS Manifest if she was approved or disapproved for the apartment” CM reiterates to the client as per P4P meeting on 7/9/2015, client was informed to be “open minded” and also there is a possibility she may not be accepted for the housing.

CM also inquires the reason the client is not participating in Palm Garden Adult Recreation. Client states “she have a lot to do”.

Demographics: Patient is a 32-year-old, moderately built Caucasian female; separated once with 2 children. She lives with her children in her mother’s town house in the North-eastern part of the province. She is currently unemployed and receiving disability from the state from sustained back injury. She has Medicaid insurance; speaks English and practices the Baptist religion.