This is sample treatment plan and assessment based on a fictional case study.

1006 WordsJul 5, 20055 Pages
The purpose of this interview was to assess the patient 's need for addiction treatment by reviewing patient 's present and previous usage history, emotional and behavioral stability, and potential for relapse, environment, pertinent medical conditions, and willingness or desire for treatment. An interview and medical records gathered this data. Name: Stan Jacobson Date: May 6, 2005 Age: 25 years old Gender: Male Ethic background: Caucasian Birth date: February 3, 1980 Residence: 161 N. Ray St. Minneapolis, MN Referral: Court ordered The client is being assessed today due to a conviction of driving under the influence. The ruling judge ordered the client to obtain professional help with addiction problems. This assessment will…show more content…
DIMENSION 5: RELAPSE POTENTIAL 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. Risk level: Due to short length of sobriety, lack of support network and relapse prevention plan, and current emotional issues, risk level is 3. DIMENSION 6: RECOVERY ENVIRONMENT Client lives alone. Client works full time in constructions and studies psychology part time at a local college. Client states he does not have any social friends and he is a 'loner '. Client has poor family relationships. Client is divorced and has a history of volatile relationships. Client has no prior involvement with self-help groups or strong support systems. Risk level: Due to lack of a supportive social network, some criminal activity, and lack of counseling services risk level is
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