A: Client appears to be in the pre-contemplation stage of change at this time.
P: Client is being discharged from treatment due to lack of engagement for treatment. / HA, CDP
Daimarkus is a 27-year-old AA male who presents to CRU 2 from UPC. He is on ACOT for PAD. Patient stated he was in prison for 3 years for attempted armed robbery, he was released on the 04/14/17. He was recently discharged from DVH. According to his Psy eval from UPC, he was stayed on COT whiles at DVH.…
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…
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.…
RF is a 49 year old man who came to the shelter off the streets. He had a history of hospitalization and was diagnosed with Bipolar Disorder and Anxiety Depression. With the help of case management, RF was able to maintain his mental health treatment and sobriety. He started off by seeing the MHAMC (Mental Health Association of Morris County) psychiatrist for medication monitoring and counseling. RF was linked to IOP at DayTop and attended AA/NA meetings at the Market Street Mission.…
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.…
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…
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.…
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.…
To the Honorable Judge Steven Smith: Mr. Joshua Sledge is a client of MTR Treatment. The client self-referred because of problematic substance use. He has been receiving treatment since February 27, 2017. To improve treatment outcomes, Mr. Sledge was assessed for possible psychopathology using the Personality Assessment Inventory (PAI).…
Intake/status alert/R.O.I/ CalOMS Client David Dietz was referred to the Quest House residential program per FSC Assessment Specialist. Client is being recommended for 90 days of inpatient treatment followed by a FSC review. Client has a tentative exit date from Quest House on 04/10/2017 Client read, understood and signed all intake documentation which includes the CalOMS admission form, release of information, Health Questionnaire, Grievance Procedures and Admission Agreement which a status alert was sent to the proper agencies. Counselor will meet with client next week to complete his TX Plan.…
Client attended 21 out of 24 IOP group sessions. However, client was not in compliance with treatment during this reporting period due to not attending groups or individual session. UA result was negative for all tested substances, which was obtained on 06/30/2017. Client will have to scheduled an appointment with his primary counselor to be able to continue this treatment. Client is in danger to be discharge from treatment due to not attending group and not response to phone call.…
John is a mandated client which means that he is required to meet with me against his will. I will need to be understanding and supportive of his situation, acknowledging that this is a difficult situation for all. It would be a challenge to motivate John into becoming actively engaged in treatment but it’s the responsibility of the John, myself and the system of care.…
There are three goals I have selected for my client in order to prevent another hospitalization: Client will participate in medical and psychological assessments at least two days prior to discharge, client will create a safety plan in the event of a medical emergency at least one day prior to discharge, and the client will build a healthy support system containing at least five individuals within six months after discharge. Goal 1 The first goal is for the client to participate in medical and psychological assessments at least two days prior to discharge. The purpose of this goal is to pinpoint the cause of the dizziness, forgetfulness, and diminishing eyesight Rose is experiencing.…
P) Client will continue to attend group counseling on Tuesdays from 6:30pm to 7:00pm.…
This writer has worked with many individuals in which have made significant progress, and this writer has felt that they were ready for termination, however, the client for whatever reason did not. This writer has learned the importance of when this happens to explore and identify what is preventing the client from being ready and working with them to overcome this. An example of this might be a client not wanting therapy to end because it is the one constant support in their life. Helping a client connect to a natural support of some sort is necessary in this situation so that the client can transition out of therapy. This writer is aware though, that the situation is not always as black and white as this, and that is where she finds the challenge arise.…