Ams Therapy Case Summary

AMS Counselor met with Pt. for the first individual session. Pt. transferred to this counselor caseload on the above date. Counselor introduced himself with name, sharing his cultural background and counseling work experience in order to develop a heathy therapeutic alliance. Counselor requested that Pt. provide an honest description of his medication effectiveness and any medication issues. Pt. verbalized how his current prescribed medication (methadone 90 mg) is working well. Primary Counselor asked him if he is having any recovery concerns and whether the he has used any drugs or alcohol since his last AMS therapy session. Pt. denied having any mental health issues at the moment. Pt. reported that the last time he used heroin was with his girlfriend. Pt. identified himself as a 21 year …show more content…
to share his financial status, future goals, his strength, how he spends his free time and what he wants to work on. Pt. stated that during his free time he likes to sleep. Pt’s strengths are being a good worker and being responsible by always paying his bills. Pt. identified that the areas that he wants to work on staying clean and being able to control his depression. Pt. shared one of his future goal is to find a job that he enjoys and that will pay him better. Pt. informed this writer that he bought a new car. Pt. reported that he agrees to pay his tx services fees every Friday. At the end of the session, Counselor explained the concept of “pay now and have fun later or have too fun now and you will paying later” and isn’t only mean work had in his job but different areas of his life. Counselor taught Pt. the six different stages of change in recovery in order to assess his current recovery status. Pt. reported that he is in the contemplation stage because he has decided to receive TX and he understand the cons of using but feels ambivalent about changing at this moment. Pt. agreed to schedule an individual session early next month at the AMS front