Lifewell South Mountain is his outpatient treatment agency. He is alert and oriented 4x. He presents as calm, appropriate and cooperative during the intake process. Patient denies DTO/DTS. He denies AH and VH, but stated he was hearing voices yesterday.…
Because of non-compliance, his reinstatement is denied. However, this writer discussed with the patient about the Apt. Foundation of which the patient is willing to consider to seek admission due to the clinic acceptance of benzodiazepine and affordable weekly fees upon speaking with an admission representative. The patient is aware of the clinic's intake dates and time as he plans to go tomorrow and once this writer received confirmation, this writer will send his record to assist with…
Client working permit expired and CAMBA Legal is working on client FOIA which it’s pending. MENTAL UPDATE: Client reports no mental health history. On 12/14/2015, client met with the on-site psychiatrist and a psychiatric evaluation was completed. Client was diagnosed with Axis1: Adjustment disorder with anxiety.…
Supervisor File and Supervision Plan Review: (Case Management and Treatment) Since the last file review, Mishai continues to adjust poorly. She has acquired multiple major and moderate infractions for failure to comply and threats to institutional infractions. She had several SIB incidents, and PO has attempted to address this issue with her to no avail. The Comprehensive Re-Entry Case Plan has been addressed with Ms. Harrington (PDSS), Mishai, the grandmother, and the JCC counselor.…
Counselor met with Pt. for his monthly individual session. Counselor and Pt. discussed his new treatment plan update objectives and interventions. Pt. agreed to sign the AMS Record of Services sheet. Counselor helped Pt.…
Group members then were presented with steps/strategies to cope identified high-risk situations. PO attended group on time, clean and sober, and had a moderate level of participation, as evidenced by sharing personal HRS openly, and demonstrating the ability on how to cope with HRS in group. PO also shared with peers about his recovery experience and ways to cope with temptation and HRS. It appears that PO has gained insight into his HRS and has been working on changing his past behavioral for his recovery. PO appears to have a strong desire to maintain her sobriety.…
I attended a hearing on your behalf in the above matter before Judge Burke in Hudson, New York on 07/18/17. The claimant was not present. His attorney, Paul Lahey, appeared by phone. As you know, this case is established for an injury to the back injury with an average weekly wage of $1,241.00. The claimant has been out of work since 2006.…
Status - uncontrolled Drug therapy problem - safety: dose too high - LS's pain medication dose is too high and at risk for opioid overdose. Drug therapy problem - indication: needs additional drug therapy - LS is at high risk for opioids overdose, a rescue medication for opioids overdose is recommended; LS needs optimal pain medications to control her symptom. Drug therapy problem - compliance: noncompliance - LS is not compliance with taking her MS Contin tablet and oxycodone IR tablet. Rationale:…
Mr. Lee has had very busy past several months. He has been not been honest in his reporting to this provider and violated the following treatment rules: -If your offense involved children, you shall not be alone with minor males or females. Whenever you have prolonged social contact with minors, an adult that is approved in advance by your treatment provider and is aware of your offense history and the behavioral rules that you must follow when around children must monitor you. -You shall not consume alcohol or use illicit substances, including prescription medication that is prescribed to another individual. -You shall not engage in any romantic/sexual behavior with any individual without my prior knowledge and approval.…
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.…
On 7/5/2016, CM met with the client to complete Bi-Weekly ILP Review. In the meeting client appears to be upset and distraught. Client mood was un-balanced and her affect was in- appropriate. Client denied suicidal or homicidal ideation. Client was dressed with proper attire for the weather.…
The reporting party (RP) on 6/12/16 stated that Kee'Riyah disclosed that she and her foster siblings are all being showered together and that her 12 year old foster brother Jhaycze is touching her legs and breast. The RP stated Kee'Riyah stated she is being hit, yelled at, and called names by them (foster siblings). The child disclosed that her ear is pulled when she gets in trouble. Per the RP the child is in an un-monitored visit from 11AM to 7PM. The RP stated she was on her way to the 77th Street Community Police Station to file a police report regarding the allegations.…
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.…
Risk Management/PI: Rachel Beal, COO Dashboard: Acute: Seclusions: July: 4 – 2.18% August: 13 – 7.78% September: 3 – 1.69% Holds: July: 6 – 3.26% August: 17 – 10.17% September: 3 – 1.69% Patient Aggression No Injury: July: 2.18% August: .06% September: 7.87% Patient Aggression Injury: July: 5.98% August: 16.76% September: 2.81% Elopements: July: 1 – .54% August: 0% September: 0% Falls: July: 2 – 1.09% August: 1 – .06% September: 0% Medication Variances: July: 7 – 4.38% August: 8 – 5.06% September: 8 – 5.11% RTC: Seclusions: July: 0% August: 0% September: 0% Holds: July: 16 – 11.81% August: 23 – 18.41% September: 17 – 15.48% Patient Aggression No…
As of now, the client has met the criteria for severe substance use disorder, with behaviors that have put the client at risk of serious physical harm and has presented with signs of withdrawal. The breaking of addiction is seriously taxing work, and the client will need all of their strength and resources dedicated to this task…