I. PERSONAL INFORMATION/REASON FOR REFERRAL
Mr. Escobar is thirty-four years old. He stated that he was born in Guatemala which is in Mexico. Mr. Escobar reported that he has lived in Georgia for fifteen years. Mr. Escobar has lived in the United States for approximately twenty-five years. Mr. Escobar stated that he is single and does not have any children. Mr. Escobar has been required to complete a substance abuse evaluation as a result of a possession of an illegal drug related offense. The evaluation is to determine whether Mr. Escobar is suffering from a Substance Related Disorder and to recommend a course of treatment, if appropriate. The interview was conducted directly and entirely in English, Mr. Escobar’s native language.
II. EMPLOYMENT/EDUCATION …show more content…
ASAM-DIMENSION 3 – Emotional, Behavioral, or Cognitive Conditions and Complications
Mr. Escobar was on time for his evaluation. Mr. Escobar appeared neat and appropriately dressed for the interview. Mr. Escobar had no noticeable tattoos. Mr. Escobar was able to establish good eye contact throughout the interview. Mr. Escobar’s posture appeared to be tense when he first sat down for the interview. Mr. Escobar appeared calm but concerned. He appeared to have normal and steady psychomotor activity throughout. Mr. Escobar’s general attitude and behavior appeared positive and cooperative. By the end of the interview, Mr. Escobar appeared to become more relaxed in his posture.
Mr. Escobar did not appear to have homicidal and/or suicidal ideation, nor did he appear to have any type of hostile, antisocial, or manipulative behaviors. Mr. Escobar’s mood and affect appeared within the normal range throughout the interview. Mr. Escobar did not appear to have any type of perceptual distortions at the time of this interview. Mr. Escobar appeared to be of average intelligence. He was alert, insightful, and well aware of the problem that led him to this clinical interview. Mr. Escobar was unaccompanied by a significant other to the …show more content…
CLINICAL SUMMARY AND IMPRESSIONS
When reviewing the information provided by Mr. Escobar, there are some concerns. He admitted to consuming marijuana and alcohol on a regular basis before 2007. There seems to be a history of an early onset of marijuana and alcohol use. Mr. Escobar reported that he has been abstinent from marijuana and alcohol. Mr. Escobar would benefit from an early intervention program in order to become educated regarding the dangers of substance use.
Mr. Escobar will also be able to process his patterns of drug use and learn to recognize triggers that lead to his substance abuse. Mr. Escobar will also be able to learn the effects and consequences of substance abuse and how to remain abstinent from drugs. While in group therapy, Mr. Escobar will learn appropriate techniques to maintain abstinence. The group will assist him in developing a supportive network to encourage him to maintain abstinence.
XIII. CLINICAL DIAGNOSTIC CLASSIFICATION
Per the information that Mr. Escobar has presented, it appears that he does not, at this time, meet any criteria to justify a diagnosis per criteria set forth by the Diagnostic and Statistical Manual (DSM), fifth (V)
Mr. Escobar is thirty-four years old. He stated that he was born in Guatemala which is in Mexico. Mr. Escobar reported that he has lived in Georgia for fifteen years. Mr. Escobar has lived in the United States for approximately twenty-five years. Mr. Escobar stated that he is single and does not have any children. Mr. Escobar has been required to complete a substance abuse evaluation as a result of a possession of an illegal drug related offense. The evaluation is to determine whether Mr. Escobar is suffering from a Substance Related Disorder and to recommend a course of treatment, if appropriate. The interview was conducted directly and entirely in English, Mr. Escobar’s native language.
II. EMPLOYMENT/EDUCATION …show more content…
ASAM-DIMENSION 3 – Emotional, Behavioral, or Cognitive Conditions and Complications
Mr. Escobar was on time for his evaluation. Mr. Escobar appeared neat and appropriately dressed for the interview. Mr. Escobar had no noticeable tattoos. Mr. Escobar was able to establish good eye contact throughout the interview. Mr. Escobar’s posture appeared to be tense when he first sat down for the interview. Mr. Escobar appeared calm but concerned. He appeared to have normal and steady psychomotor activity throughout. Mr. Escobar’s general attitude and behavior appeared positive and cooperative. By the end of the interview, Mr. Escobar appeared to become more relaxed in his posture.
Mr. Escobar did not appear to have homicidal and/or suicidal ideation, nor did he appear to have any type of hostile, antisocial, or manipulative behaviors. Mr. Escobar’s mood and affect appeared within the normal range throughout the interview. Mr. Escobar did not appear to have any type of perceptual distortions at the time of this interview. Mr. Escobar appeared to be of average intelligence. He was alert, insightful, and well aware of the problem that led him to this clinical interview. Mr. Escobar was unaccompanied by a significant other to the …show more content…
CLINICAL SUMMARY AND IMPRESSIONS
When reviewing the information provided by Mr. Escobar, there are some concerns. He admitted to consuming marijuana and alcohol on a regular basis before 2007. There seems to be a history of an early onset of marijuana and alcohol use. Mr. Escobar reported that he has been abstinent from marijuana and alcohol. Mr. Escobar would benefit from an early intervention program in order to become educated regarding the dangers of substance use.
Mr. Escobar will also be able to process his patterns of drug use and learn to recognize triggers that lead to his substance abuse. Mr. Escobar will also be able to learn the effects and consequences of substance abuse and how to remain abstinent from drugs. While in group therapy, Mr. Escobar will learn appropriate techniques to maintain abstinence. The group will assist him in developing a supportive network to encourage him to maintain abstinence.
XIII. CLINICAL DIAGNOSTIC CLASSIFICATION
Per the information that Mr. Escobar has presented, it appears that he does not, at this time, meet any criteria to justify a diagnosis per criteria set forth by the Diagnostic and Statistical Manual (DSM), fifth (V)