This writer addressed the patient's AWOL from yesterday as she reported that she overslept. This writer informed the patient about the risk of missing her dose as she is placing herself at risk for relapse, which the patient agreed to this writer comment. The patient admits to using crack cocaine by smoking, but only a…
The patient denies any HI/SI at the time of session. The patient appears to be in the contemplation stage of change as evidence by his willingness to attended AA meetings. The counselor next scheduled individual session with the patient is on Monday August 31, 2015 at 1130…
Pt. has been in the program for over 2 years and she has been able to earn level 7 take home privilege once again. Pt. recently lost her take home privileges due to counseling non-compliance. Pt. completed a take home request form and attended two groups this quarter in order to resolve tx issues. The pt. has had her take-home privileges reinstated. Pt. was provided with feedback regarding her engagement in her tx plans and she started to reach this writer and other individual with the same recovery issues to learn and improve relapse prevention skills.…
ntake/status alert/R.O.I/ CalOMS The client came to us from DBH for a 30 to 90 day treatment episode. Client was cooperative during his intake process, and completed the necessary paperwork to be admitted into the program. Client reported during his intake that Methamphetamine was his primary drug of choice and that he has been abusing it for period of 3- years. Client reported that he was 21 years of age when he first started using Meth Client was asked how many days has he used Meth in the past 30 days ? Client reported that he has used Meth 1 day out full 30 days before coming to treatment.…
PO has been unable to maintain sobriety after receiving and completing multiple Inpatient and Outpatient treatment services. It appears that PO has low commitment and desire for change. PO passively engaged in treatment and belief that his negative consequences and life struggle were due to other factors than his addiction. PO meets the ASAM criterial for a inpatient treatment services.…
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…
Cameron Group topic: Understanding Addiction PO attended group on time and moderately participated in the group activities. PO learned the definition of addiction, the addiction process, and the different types of substance(s) withdrawal symptoms. PO shared his substance use experience with peers, and identified reasons to stay clean and sober. PO completed the weekly treatment progress, which indicated he attended 2 sober meetings last week. Verification was provided.…
The reporting party (RP) is resident Danny Madrid DOB: 8/20/91 who disclosed he was recently released from Cedar Sinai Hospital. On 10/04/16 the RP walked into the Children's Institute located at 701 S. New Hampshire Ave., Los Angeles CA 90005. Per staff member Kimberly Orellana the RP walked into the institute requesting foster care assistance for the homeless. The RP was informed the Institute only provides services to children less than 18 years of age. The RP disclosed to the staff member he had not food, nowhere to sleep, and no resources.…
The reporting party (RP) stated he received a letter date 12/31/15 from CalPERS Investigation Branch. The letter consisted of a completed review of her plan of care. According to the review CalPERS was paying for services not rendered. The facility was charging for dependent toileting, dependent diapering, and dependent showering. The RP stated he received an invoice/accounts receivable from Lilian Mendez (562) 777-1477 showing services 1-4.…
The reporting party (RP) stated she received a call from parent Lisa Hohloch the mother of Bella Hohloch age 5 stated that her daughter was shoved. The mother stated Bella disclosed that on 9/25/15 Director/Teacher Cindra Kallabis shoved her down onto a chair hurting her bottom; the director is also yelled at Bella telling her to "stay there." The RP stated the incident did not occur and that she had no interaction with Bella during the time of the incident which was during lunch at around 12:00PM. According to the RP three other teachers were present during the lunch period Jacqueline Welch Danielson, Cynthia Wilkinson, and Haily Britton. The RP stated she again spoke with Bella's mother regarding the allegation and once again Bella disclosed…
Therapist and client created treatment goals and review them. At the end of the session Robin states that she has drug court on 7/20/2016 and requested a letter stating that she sought…
Reporting party (RP) stated that on 7/18/17, she was contacted by staff due to an incident involving her daugher Olivia Quilles (DOB: 09/18/14). When RP arrived at the school, the director disclosed that the child's hand was slammed in the door while the children were standing in line to go outside. It was reported that the teacher turned her back for a second and the children starting exiting the building and the door leading to the playground was slammed onto the child's hand. RP immediately took the child to Kaiser where is was determined that she sustained a fracture on the right hand and one of her fingers (from the wrist down). The child will be in a cast for the next 8 weeks.…
Problem # 5: illicit opiate use Goal(s): to become drug free Status: active Objectives/Progress: Pt. has been able to maintain her commitment to abstinence from all illicit substances as indicated by submitting 10 negative UDS results and she reported no relapse in over 3 years. Pt. maintained her Phase 7 privileges over the last quarter. Pt. demonstrated good use of tx skills by balancing work and treatment obligations. Pt. reports that she is taking her subutex medication as prescribed by AMS Doctor and she maintained stability.…
When clarifying the presenting problem it is important to figure our what happened before, during, and after the presenting problem. In this family’s case it is important to figure out what happened before, during, and after Brenda’s relapse. This stage can be reached…
The chronic alcoholics and addicts remained on my caseload, but a new variety of clients referred due to drunk driving offense, underage drinking, or low level drug offenses lightened the load. This environment also let me expand my skills into program administration and development. I was given the opportunity to develop a women’s specific treatment group and administer a presentencing program for Operating While Intoxicated offenders. I was doing very well for a 24 year…