CLIENT NAME M CASE # 1 THERAPIST NAME & CREDENTIALS Pifer, T. MHC Intern DATE 1/26/18 LENGTH OF SERVICE 28 days TYPE OF CONTACT: individual and group NO. IN GROUP 9-12
INTAKE ASSESSMENT / ADMISSION NOTE
IDENTIFYING INFORMATION: M is a 68-year-old Caucasian married male veteran. He is retired and currently resides with his wife (RN) who is still employed.
REASON FOR REFERRAL: M seeks help voluntarily for alcohol dependency, depression and suicidal ideation. He reported, "I think she's going to leave me this time. I won't be around much longer if that happens. I need to stop". His wife has noticed an increase in depression and alcohol consumption and tolerance for the past three years. The marriage is under a great deal of strain at this time. M states, "I am at the end of my string. Hopeless". …show more content…
After he retired he started his own fire wood business but no longer has that business due to declining health. M does not go to social functions with his family. Wife and son are his primary support system.
EDUCATION/EMPLOYMENT HISTORY: Highest grade M completed is some high school (dropped out). He joined the military and was honorably discharged after three years. He is retired from Union Iron Works. M worked his fire wood business in which he chopped the wood, until he began to have physical problems and limited mobility.
MEDICAL HISTORY: M has a history of atrial fibrillation, anxiety, depression, and seasonal allergies. He has been hospitalized previously for five surgeries to include three on his knee, two on his neck and one for his hip. M denies any other illnesses. Medications currently prescribed are Gabapentin, Xarelto, multivitamin, Celebrex, Celexa, Zanaglex, Amioderone. He has allergies to Cymbalta, Pamelor, Amantadine. M currently has alcoholism, depression, suicidal ideations and dyskinesia for which he will be on fall
INTAKE ASSESSMENT / ADMISSION NOTE
IDENTIFYING INFORMATION: M is a 68-year-old Caucasian married male veteran. He is retired and currently resides with his wife (RN) who is still employed.
REASON FOR REFERRAL: M seeks help voluntarily for alcohol dependency, depression and suicidal ideation. He reported, "I think she's going to leave me this time. I won't be around much longer if that happens. I need to stop". His wife has noticed an increase in depression and alcohol consumption and tolerance for the past three years. The marriage is under a great deal of strain at this time. M states, "I am at the end of my string. Hopeless". …show more content…
After he retired he started his own fire wood business but no longer has that business due to declining health. M does not go to social functions with his family. Wife and son are his primary support system.
EDUCATION/EMPLOYMENT HISTORY: Highest grade M completed is some high school (dropped out). He joined the military and was honorably discharged after three years. He is retired from Union Iron Works. M worked his fire wood business in which he chopped the wood, until he began to have physical problems and limited mobility.
MEDICAL HISTORY: M has a history of atrial fibrillation, anxiety, depression, and seasonal allergies. He has been hospitalized previously for five surgeries to include three on his knee, two on his neck and one for his hip. M denies any other illnesses. Medications currently prescribed are Gabapentin, Xarelto, multivitamin, Celebrex, Celexa, Zanaglex, Amioderone. He has allergies to Cymbalta, Pamelor, Amantadine. M currently has alcoholism, depression, suicidal ideations and dyskinesia for which he will be on fall