Does the consumer have a history of property destruction?
Assignment: Practicum – Week 8 Journal Entry
This week, you complete a two-part journal entry.
Learning Objectives
Students will:
Develop diagnoses for clients receiving psychotherapy*
Evaluate efficacy of existential-humanistic therapy for clients*
Analyze legal and ethical implications of counseling clients with psychiatric disorders*
Analyze clinical supervision experiences*
* The Assignment related to this Learning Objective is introduced this week and submitted in Week 10.
For Part 1, select a client whom you observed or counseled this week (other than the client used for this week’s Discussion). Then, address the following in your Practicum Journal:
Describe the client and identify any pertinent history or medical information, including prescribed medications.
Using the DSM-5, explain and justify your diagnosis for this client.
Explain whether existential-humanistic therapy would be beneficial with this client. Include expected outcomes based on this therapeutic approach.
Explain any legal and/or ethical implications related to counseling this client.
Support your approach with evidence-based literature.
For Part 2, reflect on your clinical supervision experiences. Then, address the following in your Practicum Journal:
How often are you receiving clinical supervision from your preceptor?
What are the sessions like?
What is the preceptor bringing to your attention?
How are you translating these sessions to your clinical practice?
Please use this scenario of a 55-year-old male
Hopes, Dreams, Accomplishments, Challenges, Needs
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Assessment Date: 04/02/2020
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Assessment is: Initial
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If you are reviewing an existing D&A that is still valid, make any necessary changes to the Assessment in this form.
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‘How can we help you?’ as stated during Enrollment (From Profile):
Csr called DC DBH AHL with LES to request transfer to LES from Preventive Measures for Schizophrenia. Csr reports dissatisfaction with services at Preventive Measures. Csr enrolled with LES, per csr request.
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Enter ‘How can we help you?’ if not shown above or provide updated information regarding the reason seeking services:
“I just need help to continue to manage my mental health. I need consistent services and make sure I have all of the things I need to take care of myself and mental health”.
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Check to describe Strengths and Community Supports that will affect treatment? (maps to Profile field):
“If I am not being treated the way I think after I tell you what I need, I will find new services”.
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Check to describe Barriers that may affect treatment? (maps to Profile field): Describe below
“None, that I can think of”.
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How will you know when your work with us is done?:
“I will always have a need for mental health because I will be on medication for the rest of my life because of my diagnosis. I have to have treatment to manage my mental health”.
LIVING SITUATION
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Living Situation (taken at Enrollment – update below if necessary):
INDEPENDENT LIVING
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Living Situation: Alone
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Housing Type: Independent Apartment
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Housing Program: Federal Voucher
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Is the consumer a child/youth?: No
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Satisfaction with Living Situation: Very Satisfied
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Check box to describe the consumer’s living situation (Domain 1 Narrative): Describe Below
“I have been in my apartment for 2 years and I love it. I am current with my rent and other bills”.
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Check box to describe consumer strengths, resource, and skills related to living situation:
“I have been able to maintain my apartment for the past 2 years”.
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Stage of Change: Person does not wish to address at this time
FAMILY
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Family (from Consumer Family):
Name:Ricky Houser
Dependent:False
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Check to describe the consumer’s family of origin history (birth order, upbringing, history of moves, etc.). (Domain 2 Narrative): Describe Below
“I was born and raised in Washington, D.C. My parents did not raise me. I was supposed to be raise by my father because my mother was out and able to raise me. I have 2 sisters and 5 brothers. I am the oldest of my siblings. My father was married and I was raised by my step-mother”.
I was married and my wife died in 2010. I have been a widower and I have no children.
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Check to describe any family history of mental illness and/or substance use disorders.:
“I think my parents had problems but I am not sure I if they got any help”.
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Check to describe the consumer’s family and how the family impacts her/him now. Note significant events and how they affected the consumer and identify family members the consumer wishes to participate in her/his treatment. (Domain 2 Narrative): Describe Below
“I do not have a regular relationship with my family”.
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Check to describe the quality of family relationships currently, and growing up.:
“I miss my wife so much, she was my support”.
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Is the consumer a parent?: No
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Check box to describe consumer strengths, resources, and skills related to family:
“I miss my wife”.
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Stage of Change: Person does not wish to address at this time
SOCIAL/RECREATION
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Check to describe the consumer’s peer group, what they have in common, their shared interests and activities, which peers the consumer wishes to participate in her/his treatment and the and consumer’s activities in his/her free time. (Domain 3 Narrative): Describe Below
“I like music, games on my cellphone and television”.
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Check box to describe consumer strengths, resources, and skills related to social/recreation:
“I make sure I relax and deal with things”.
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Stage of Change: Person does not wish to address at this time
EDUCATIONAL
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School Status: Dropped Out
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School Grade : Tenth
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School Attendance: N/A
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Check box to describe consumer strengths, resources, and skills related to Education:
Daniel disclosed he stopped school in the 10th grade.
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Stage of Change: Person does not wish to address at this time
MILITARY SERVICE
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Military Service?: No
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Stage of Change: Person does not wish to address at this time
EMPLOYMENT
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Employment Status: Not in Labor Force (retired, student, volunteer)
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Occupation: unemployed
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Income Verified?: No
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Supported Employment Status: Eligible, Not Enrolled
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Supportive Employment Interest?: No
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Supportive Employment Offered?: Declined due to physical health concerns
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Check to describe the consumer’s financial status?: Describe Below
Daniel disclosed he gets $75.00 a month and food stamps.
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Check to describe the consumer’s work and volunteer history, including vocational training; note if the client would like to work again and, if so, what type of work. (Domain 5 Narrative):
Daniel disclosed he has worked but it’s been years ago. He disclosed because of his mental health challenges, he can not work at this time.
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Check box to describe consumer strengths, resources, and skills related to employment:
Has a work history
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Stage of Change: Person does not wish to address at this time
EMOTIONAL/BEHAVIORAL/DEVE
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Emotional/Behavioral/Developmental
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Describe the consumer’s history of involvement with the mental health system, both inpatient and outpatient. Note age and circumstances at onset and significant events since then.: Description below
Daniel begun mental health services in 2014 and these services has included 35K to several CSAs. His most recent CSA was Preventive Measures. Daniel disclosed he only sought outpatient mental health services as well as addiction services. Daniel stated he has no history of inpatient services.
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Check to describe the consumers current emotional and behavioral functioning. Note maladaptive or problem behaviors. (Domain 6 Narrative): Description below
Daniel disclosed his emotions and behavioral functioning is being managed my medication. “If I was not on medication I would be all over the place, hearing things as well. I have had the following symptoms, social isolation, disorganized behavior, agitation, repetitive movements, thought disorders,disorientation, anxiety, anger, feelings of detachment and inappropriate emotional responses”.
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Describe the consumers history of emotional and/or behavioral problems (hallucinations, etc).: Description below
“I have been having problems for years. However, for almost 4 or 5 years I have been consistent with things and managing mental illness with medications. I have been able to keep my symptoms manageable with medications. When I start to have problems I have been seeking help. I have had all of the above problems, social isolation, disorganized behavior, agitation, repetitive movements, thought disorders,disorientation, anxiety, anger, feelings of detachment and inappropriate emotional responses.
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Check box to describe emotional/behavioral/developmental consumer strengths:
“Medication and having a community support worker has helped to manage my life better”.
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Does the consumer have an Intellectual and Development Disability?: No
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Is the consumer experiencing any disruptions in eating or sleeping patterns?: No
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Is the consumer able to self sooth and regulate emotions in response to change or stressors?: Yes
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Does the consumer have any mood related symptoms?: Yes
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Mood related symptoms include: Anxious/worried, Mood swings, Poor concentration/difficulty making decisions, Psychomotor agitation or retardation, Hypomanic/Manic
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Is there DDS involvement?: No
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Identified Challenging Behaviors, if any: (check boxes and elaborate): Other (describe)
“Daniel disclosed in the past he has had problems with managing his symptoms however, medication has helped in to manage his symptoms as well as daily behaviors”.
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Functional Assessment Completed: No
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Behavior Support Plan Developed?: No
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Is Consumer a child (or is childhood development a concern?): No
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PRENATAL HISTORY:
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CHILD’S HEALTH
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LANGUAGE DEVELOPMENT
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BIRTH/EARLY CHILDHOOD HISTORY
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LEGAL
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Use Consumer Intake link to enter Legal Representative, Parole and Probation officers in the Contacts.
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History of arrest/Incarceration?: No
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Stage of Change: Person does not wish to address at this time
SPIRITUAL/CULTURAL
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Does the consumer have a spiritual belief/practice?: No
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Is cultural identity important to the consumer?: No
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Stage of Change: Person does not wish to address at this time
HEALTH
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Medical Profile (from Profile):
Date Created:6/11/2018
Vision:Normal with correction
Hearing:Normal without correction
Mobility:Walks independently
Other Specified:rod in R leg and L arm- pt reports getting hit by car 4yrs ago.
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Medical Profile Header (from Profile):
BMI:-1.00
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No Allergy Flag?:
True
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SUD Status: History of Use
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Smoking Status: Former smoker
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Sexual Orientation: Heterosexual
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HIV Status: HIV Negative
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Describe the consumer’s sexual history (include attitudes toward sex and sexuality, past and current sexual behaviors, and safer sex practices if applicable, age of first menstruation for women, history of pregnancies, history of STDs).: Describe Below
“I do not remember what age I begun having sex, I think it was 17 or 18 years old. I have not had any STDs. I do practice safe sex. I do not have children. I believe sexual behavior should be taken serious and with thoughtful commitment”.
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Describe the consumer’s health status (include current health issues, health history and any significant family health issues).: Describe Below
“I have asthma and I am not on medications. I do need a PCP”.
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Check to describe consumer strengths, resources and skills related to Health issues (how does the situation relate to the consumer’s condition and how will it impact her/his care and treatment?): Describe Below
“I try to stay healthy”.
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Stage of Change: Person does not wish to address at this time
MEDICATIONS
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Medications:
Medication:trazodone 50 mg tablet
Start Date:8/16/2017
Dosage:50 mg
Frequency:at bedtime
Quantity:30
Provider:Atlener Artis-Trower
Refills:0
Medication:Abilify 10 mg tablet
Start Date:6/16/2017
Quantity:30
Provider:Sana Kamal
Refills:0
Medication:Latuda 20 mg tablet
Start Date:3/8/2016
Quantity:30
Provider:Sana Kamal
Refills:1
Medication:Benadryl 50 mg capsule (inactive)
Start Date:3/8/2016
Quantity:30
Provider:Sana Kamal
Refills:1
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No Medications Flag?:
False
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Has the consumer been prescribed psychiatric medications in the past?: Yes
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How does the consumer feel about taking psychiatric medications? Does s/he take them as prescribed? If not, why not?:
“My medication has helped to function so much better, I have been in my apartment for the past 2 years without any problems. I have to have my medication because my life is so much better with the medication. I function so much better and can manage my life”.
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Has the consumer been prescribed medications for a medical condition in the past?: Yes
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How does the consumer feel about taking medications for medical conditions? Does s/he take them as prescribed? If not, why not?:
“I take my medication like I am supposed to take it”.
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Describe any medications/medication side effects that the consumer wishes to avoid.:
Denied and denied having any allergies to medication or food.
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Check to describe consumer strengths, resources and skills related to Medication issues (how does the situation relate to the consumer’s condition and how will it impact her/his care and treatment?): Describe Below
“I do take my medications”.
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Stage of Change: Maintenance
TRAUMA/ABUSE HISTORY
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Check regarding whether the client has been a victim or perpetrator of any of the following:
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Physical assault (The use of force against a person with the intent, or result, being physical injury): No History
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Rape (Sexual abuse, assault, violation, attack, or force): No History
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Sexual molestation (Unwanted and intrusive sexual advances, up to but not including rape): No History
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Domestic abuse (Maltreatment caused by a spouse or significant other resulting in physical or psychological injury): No History
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Elder neglect or abuse (Maltreatment of an elderly person resulting in physical or psychological injury; or the absence of services or resources to meet basic needs): No History
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Child neglect or abuse (Maltreatment of a child resulting in physical or psychological injury; or the absence of services or resources to meet basic needs): No History
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Exploitation (The taking of unjust advantage of another for one’s own benefit): No History
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Neighborhood and Community Violence: No History
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Bullying: No History
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Other: (any other trauma as described by the consumer. Examples may include accidents, natural disasters, etc): No History
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For the clinician: Is there any evidence of trauma or abuse (bruises, scratches, broken bones, etc.)? If yes, does the consumer’s explanation for the evidence seem plausible?: No
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Stage of Change: Person does not wish to address at this time
RISK ASSESSMENT
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Have you ever had thoughts about killing yourself?: No
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Have you ever taken action to kill yourself?: No
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Have you ever had thoughts of harming/killing someone else?: No
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Have you ever taken action to harm/kill someone else?: No
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Does the consumer have a history of self harm without suicidal intent?: No
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Does the consumer have a history of running away?: No
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Does the consumer have a history of cruelty towards animals?: No
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Does the consumer have a history of fire-setting?: No
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Does the consumer have a history of stealing?: No
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Does the consumer have a history of property destruction?: No
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Does the consumer have a history of risky sexual behavior?: No
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Stage of Change: Person does not wish to address at this time
SUBSTANCE USE ASSESS
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History or Current Substance Use?: Yes
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Was a GAIN-SS completed?: Yes
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When did you start using?or start your addictive behavior e.g. gambling, shopping, eating, etc.?) age? duration? patterns of use? what would you say got you started?: Description below
“I used drugs for over 24 years and I stopped using drugs over 10 years ago. My drug of choice was crack cocaine. I begun using to help manage my mood and just needing an escape as I look back over my life. I would use daily”.
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As a result of your drug use / addictive behavior, have you ever: been arrested? hospitalized – psychiatric or physical? had relational / family problems? had emotional problems? employment interruption?: Describe below
Denied
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Has your use of any of the substances above caused you to have health or physical problems (blackouts, withdrawals, injuries, liver problems, etc.)?: Describe below
“I was addicted and believe I needed it daily”.
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History of family members’ use of alcohol, other drugs, and other addictive behaviors: Describe below
“I believe my parents had some problems”.
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Have you ever received inpatient or outpatient treatment for your substance abuse or addictive behavior(s)? If so, where, when, and for how long? Reason (voluntary, mandated)? Response? Longest period of sobriety/abstinence? Relapses?: Describe below
Denied
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Check to describe consumer strengths, resources and skills related to Substance Use issues (how does the situation relate to the consumer’s condition and how will it impact her/his care and treatment?): Describe Below
“I stopped using on my own and I have been clean since that time. Howvever, dealing with my mental health and getting on medication has helped me with managing my addiction”.
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Stage of Change: Person does not wish to address at this time
MENTAL STATUS EXAM
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Physical Appearance: Appropriate
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Motor Activity/Involuntary Movements: WNL
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Behavior: Cooperative
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Speech: WNL
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Mood: WNL
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Affect: Appropriate
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Thought Process: Logical
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Thought Content: Appropriate
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Delusions: None
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Suicidal Ideation: None
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Homicidal Ideation: None
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Hallucinations/Perceptions: None
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Intelligence: Average
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Insight: Good
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Judgment: WNL
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Attention: WNL
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Orientation: Person, Place, Date, Purpose
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Memory: WNL
CLINICAL INTERPRETIVE SUM
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The Clinical Summary is based on information provided by (check all that apply): Consumer, Records
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Diagnosing AQP Assessment Summary, recommended level of care, recommendations for treatment, and criteria for transition to lower level of care and/or discharge:
Daniel is a 55 year old male who was born and raised in Washington, D.C. He disclosed his parents were around however, they did not raise him. Daniel disclosed he was raised by his step-mother. He is the oldest of 8 siblings, 2 sisters and 5 brothers. Daniel disclosed he had a good relationship with is step-mother and siblings.
Daniel was married, his wife died in 2010. He disclosed he does not have any children.
Daniel disclosed he used crack cocaine for 24 years and decided to stop using about 10 or 12 years ago. He disclosed he stopped and has not used since that day. Daniel denied going to treatment for addiction.
Daniel has an extensive mental health history. He begun services in 2014 and his most recent mental health treatment provider was Preventive Measures. Daniel disclosed being placed on medication years ago helped him to gain control over his life and manage his mental health. He stated medication has made a difference. “Since being on medication I have so much more control over my life and relationships. I have my own apartment for the past 2 years. It’s been good. I am current with all of my reponsiblities”. Daniel does not work and is not eligble for SSDI. He applied and was denied because has not put enough money into the society system for SSDI.
Daniel disclosed prior to beginning consistently to take his medication he used to experience the following symptoms, social isolation, disorganized behavior, agitation, compulsive behaviors, repetitive movements, thought disorders, anxiety, anger, feelings of detachment, elevated mood, feeling tired and hearing voices. Daniel meets the criteria for F29, Unspecified Psychotic Disorder.
Daniel is being recommended for a psychiatric assessment with medication to assist him with ongoing stablization for symptoms, individual therapy to address his underlying behavioral and cognitive challenges and community support worker services to assist him with implementing skills into his daily life functioning and supportive services for community resources including assisting him with obtaining a PCP.
Daniel will be discharged to a lower level of care once he is stablized and able function independently with managing his symptoms and being consistent with mental and physical health care.Assignment: Practicum – Week 8 Journal Entry
This week, you complete a two-part journal entry.
Learning Objectives
Students will:
Develop diagnoses for clients receiving psychotherapy*
Evaluate efficacy of existential-humanistic therapy for clients*
Analyze legal and ethical implications of counseling clients with psychiatric disorders*
Analyze clinical supervision experiences*
* The Assignment related to this Learning Objective is introduced this week and submitted in Week 10.
For Part 1, select a client whom you observed or counseled this week (other than the client used for this week’s Discussion). Then, address the following in your Practicum Journal:
Describe the client and identify any pertinent history or medical information, including prescribed medications.
Using the DSM-5, explain and justify your diagnosis for this client.
Explain whether existential-humanistic therapy would be beneficial with this client. Include expected outcomes based on this therapeutic approach.
Explain any legal and/or ethical implications related to counseling this client.
Support your approach with evidence-based literature.
For Part 2, reflect on your clinical supervision experiences. Then, address the following in your Practicum Journal:
How often are you receiving clinical supervision from your preceptor?
What are the sessions like?
What is the preceptor bringing to your attention?
How are you translating these sessions to your clinical practice?
Please use this scenario of a 55-year-old male
Hopes, Dreams, Accomplishments, Challenges, Needs
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Assessment Date: 04/02/2020
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Assessment is: Initial
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If you are reviewing an existing D&A that is still valid, make any necessary changes to the Assessment in this form.
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‘How can we help you?’ as stated during Enrollment (From Profile):
Csr called DC DBH AHL with LES to request transfer to LES from Preventive Measures for Schizophrenia. Csr reports dissatisfaction with services at Preventive Measures. Csr enrolled with LES, per csr request.
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Enter ‘How can we help you?’ if not shown above or provide updated information regarding the reason seeking services:
“I just need help to continue to manage my mental health. I need consistent services and make sure I have all of the things I need to take care of myself and mental health”.
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Check to describe Strengths and Community Supports that will affect treatment? (maps to Profile field):
“If I am not being treated the way I think after I tell you what I need, I will find new services”.
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Check to describe Barriers that may affect treatment? (maps to Profile field): Describe below
“None, that I can think of”.
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How will you know when your work with us is done?:
“I will always have a need for mental health because I will be on medication for the rest of my life because of my diagnosis. I have to have treatment to manage my mental health”.
LIVING SITUATION
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Living Situation (taken at Enrollment – update below if necessary):
INDEPENDENT LIVING
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Living Situation: Alone
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Housing Type: Independent Apartment
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Housing Program: Federal Voucher
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Is the consumer a child/youth?: No
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Satisfaction with Living Situation: Very Satisfied
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Check box to describe the consumer’s living situation (Domain 1 Narrative): Describe Below
“I have been in my apartment for 2 years and I love it. I am current with my rent and other bills”.
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Check box to describe consumer strengths, resource, and skills related to living situation:
“I have been able to maintain my apartment for the past 2 years”.
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Stage of Change: Person does not wish to address at this time
FAMILY
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Family (from Consumer Family):
Name:Ricky Houser
Dependent:False
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Check to describe the consumer’s family of origin history (birth order, upbringing, history of moves, etc.). (Domain 2 Narrative): Describe Below
“I was born and raised in Washington, D.C. My parents did not raise me. I was supposed to be raise by my father because my mother was out and able to raise me. I have 2 sisters and 5 brothers. I am the oldest of my siblings. My father was married and I was raised by my step-mother”.
I was married and my wife died in 2010. I have been a widower and I have no children.
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Check to describe any family history of mental illness and/or substance use disorders.:
“I think my parents had problems but I am not sure I if they got any help”.
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Check to describe the consumer’s family and how the family impacts her/him now. Note significant events and how they affected the consumer and identify family members the consumer wishes to participate in her/his treatment. (Domain 2 Narrative): Describe Below
“I do not have a regular relationship with my family”.
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Check to describe the quality of family relationships currently, and growing up.:
“I miss my wife so much, she was my support”.
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Is the consumer a parent?: No
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Check box to describe consumer strengths, resources, and skills related to family:
“I miss my wife”.
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Stage of Change: Person does not wish to address at this time
SOCIAL/RECREATION
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Check to describe the consumer’s peer group, what they have in common, their shared interests and activities, which peers the consumer wishes to participate in her/his treatment and the and consumer’s activities in his/her free time. (Domain 3 Narrative): Describe Below
“I like music, games on my cellphone and television”.
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Check box to describe consumer strengths, resources, and skills related to social/recreation:
“I make sure I relax and deal with things”.
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Stage of Change: Person does not wish to address at this time
EDUCATIONAL
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School Status: Dropped Out
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School Grade : Tenth
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School Attendance: N/A
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Check box to describe consumer strengths, resources, and skills related to Education:
Daniel disclosed he stopped school in the 10th grade.
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Stage of Change: Person does not wish to address at this time
MILITARY SERVICE
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Military Service?: No
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Stage of Change: Person does not wish to address at this time
EMPLOYMENT
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Employment Status: Not in Labor Force (retired, student, volunteer)
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Occupation: unemployed
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Income Verified?: No
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Supported Employment Status: Eligible, Not Enrolled
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Supportive Employment Interest?: No
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Supportive Employment Offered?: Declined due to physical health concerns
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Check to describe the consumer’s financial status?: Describe Below
Daniel disclosed he gets $75.00 a month and food stamps.
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Check to describe the consumer’s work and volunteer history, including vocational training; note if the client would like to work again and, if so, what type of work. (Domain 5 Narrative):
Daniel disclosed he has worked but it’s been years ago. He disclosed because of his mental health challenges, he can not work at this time.
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Check box to describe consumer strengths, resources, and skills related to employment:
Has a work history
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Stage of Change: Person does not wish to address at this time
EMOTIONAL/BEHAVIORAL/DEVE
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Emotional/Behavioral/Developmental
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Describe the consumer’s history of involvement with the mental health system, both inpatient and outpatient. Note age and circumstances at onset and significant events since then.: Description below
Daniel begun mental health services in 2014 and these services has included 35K to several CSAs. His most recent CSA was Preventive Measures. Daniel disclosed he only sought outpatient mental health services as well as addiction services. Daniel stated he has no history of inpatient services.
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Check to describe the consumers current emotional and behavioral functioning. Note maladaptive or problem behaviors. (Domain 6 Narrative): Description below
Daniel disclosed his emotions and behavioral functioning is being managed my medication. “If I was not on medication I would be all over the place, hearing things as well. I have had the following symptoms, social isolation, disorganized behavior, agitation, repetitive movements, thought disorders,disorientation, anxiety, anger, feelings of detachment and inappropriate emotional responses”.
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Describe the consumers history of emotional and/or behavioral problems (hallucinations, etc).: Description below
“I have been having problems for years. However, for almost 4 or 5 years I have been consistent with things and managing mental illness with medications. I have been able to keep my symptoms manageable with medications. When I start to have problems I have been seeking help. I have had all of the above problems, social isolation, disorganized behavior, agitation, repetitive movements, thought disorders,disorientation, anxiety, anger, feelings of detachment and inappropriate emotional responses.
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Check box to describe emotional/behavioral/developmental consumer strengths:
“Medication and having a community support worker has helped to manage my life better”.
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Does the consumer have an Intellectual and Development Disability?: No
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Is the consumer experiencing any disruptions in eating or sleeping patterns?: No
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Is the consumer able to self sooth and regulate emotions in response to change or stressors?: Yes
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Does the consumer have any mood related symptoms?: Yes
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Mood related symptoms include: Anxious/worried, Mood swings, Poor concentration/difficulty making decisions, Psychomotor agitation or retardation, Hypomanic/Manic
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Is there DDS involvement?: No
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Identified Challenging Behaviors, if any: (check boxes and elaborate): Other (describe)
“Daniel disclosed in the past he has had problems with managing his symptoms however, medication has helped in to manage his symptoms as well as daily behaviors”.
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Functional Assessment Completed: No
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Behavior Support Plan Developed?: No
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Is Consumer a child (or is childhood development a concern?): No
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PRENATAL HISTORY:
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CHILD’S HEALTH
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LANGUAGE DEVELOPMENT
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BIRTH/EARLY CHILDHOOD HISTORY
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LEGAL
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Use Consumer Intake link to enter Legal Representative, Parole and Probation officers in the Contacts.
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History of arrest/Incarceration?: No
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Stage of Change: Person does not wish to address at this time
SPIRITUAL/CULTURAL
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Does the consumer have a spiritual belief/practice?: No
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Is cultural identity important to the consumer?: No
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Stage of Change: Person does not wish to address at this time
HEALTH
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Medical Profile (from Profile):
Date Created:6/11/2018
Vision:Normal with correction
Hearing:Normal without correction
Mobility:Walks independently
Other Specified:rod in R leg and L arm- pt reports getting hit by car 4yrs ago.
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Medical Profile Header (from Profile):
BMI:-1.00
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No Allergy Flag?:
True
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SUD Status: History of Use
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Smoking Status: Former smoker
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Sexual Orientation: Heterosexual
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HIV Status: HIV Negative
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Describe the consumer’s sexual history (include attitudes toward sex and sexuality, past and current sexual behaviors, and safer sex practices if applicable, age of first menstruation for women, history of pregnancies, history of STDs).: Describe Below
“I do not remember what age I begun having sex, I think it was 17 or 18 years old. I have not had any STDs. I do practice safe sex. I do not have children. I believe sexual behavior should be taken serious and with thoughtful commitment”.
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Describe the consumer’s health status (include current health issues, health history and any significant family health issues).: Describe Below
“I have asthma and I am not on medications. I do need a PCP”.
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Check to describe consumer strengths, resources and skills related to Health issues (how does the situation relate to the consumer’s condition and how will it impact her/his care and treatment?): Describe Below
“I try to stay healthy”.
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Stage of Change: Person does not wish to address at this time
MEDICATIONS
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Medications:
Medication:trazodone 50 mg tablet
Start Date:8/16/2017
Dosage:50 mg
Frequency:at bedtime
Quantity:30
Provider:Atlener Artis-Trower
Refills:0
Medication:Abilify 10 mg tablet
Start Date:6/16/2017
Quantity:30
Provider:Sana Kamal
Refills:0
Medication:Latuda 20 mg tablet
Start Date:3/8/2016
Quantity:30
Provider:Sana Kamal
Refills:1
Medication:Benadryl 50 mg capsule (inactive)
Start Date:3/8/2016
Quantity:30
Provider:Sana Kamal
Refills:1
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No Medications Flag?:
False
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Has the consumer been prescribed psychiatric medications in the past?: Yes
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How does the consumer feel about taking psychiatric medications? Does s/he take them as prescribed? If not, why not?:
“My medication has helped to function so much better, I have been in my apartment for the past 2 years without any problems. I have to have my medication because my life is so much better with the medication. I function so much better and can manage my life”.
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Has the consumer been prescribed medications for a medical condition in the past?: Yes
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How does the consumer feel about taking medications for medical conditions? Does s/he take them as prescribed? If not, why not?:
“I take my medication like I am supposed to take it”.
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Describe any medications/medication side effects that the consumer wishes to avoid.:
Denied and denied having any allergies to medication or food.
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Check to describe consumer strengths, resources and skills related to Medication issues (how does the situation relate to the consumer’s condition and how will it impact her/his care and treatment?): Describe Below
“I do take my medications”.
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Stage of Change: Maintenance
TRAUMA/ABUSE HISTORY
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Check regarding whether the client has been a victim or perpetrator of any of the following:
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Physical assault (The use of force against a person with the intent, or result, being physical injury): No History
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Rape (Sexual abuse, assault, violation, attack, or force): No History
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Sexual molestation (Unwanted and intrusive sexual advances, up to but not including rape): No History
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Domestic abuse (Maltreatment caused by a spouse or significant other resulting in physical or psychological injury): No History
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Elder neglect or abuse (Maltreatment of an elderly person resulting in physical or psychological injury; or the absence of services or resources to meet basic needs): No History
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Child neglect or abuse (Maltreatment of a child resulting in physical or psychological injury; or the absence of services or resources to meet basic needs): No History
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Exploitation (The taking of unjust advantage of another for one’s own benefit): No History
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Neighborhood and Community Violence: No History
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Bullying: No History
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Other: (any other trauma as described by the consumer. Examples may include accidents, natural disasters, etc): No History
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For the clinician: Is there any evidence of trauma or abuse (bruises, scratches, broken bones, etc.)? If yes, does the consumer’s explanation for the evidence seem plausible?: No
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Stage of Change: Person does not wish to address at this time
RISK ASSESSMENT
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Have you ever had thoughts about killing yourself?: No
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Have you ever taken action to kill yourself?: No
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Have you ever had thoughts of harming/killing someone else?: No
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Have you ever taken action to harm/kill someone else?: No
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Does the consumer have a history of self harm without suicidal intent?: No
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Does the consumer have a history of running away?: No
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Does the consumer have a history of cruelty towards animals?: No
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Does the consumer have a history of fire-setting?: No
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Does the consumer have a history of stealing?: No
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Does the consumer have a history of property destruction?: No
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Does the consumer have a history of risky sexual behavior?: No
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Stage of Change: Person does not wish to address at this time
SUBSTANCE USE ASSESS
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History or Current Substance Use?: Yes
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Was a GAIN-SS completed?: Yes
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When did you start using?or start your addictive behavior e.g. gambling, shopping, eating, etc.?) age? duration? patterns of use? what would you say got you started?: Description below
“I used drugs for over 24 years and I stopped using drugs over 10 years ago. My drug of choice was crack cocaine. I begun using to help manage my mood and just needing an escape as I look back over my life. I would use daily”.
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As a result of your drug use / addictive behavior, have you ever: been arrested? hospitalized – psychiatric or physical? had relational / family problems? had emotional problems? employment interruption?: Describe below
Denied
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Has your use of any of the substances above caused you to have health or physical problems (blackouts, withdrawals, injuries, liver problems, etc.)?: Describe below
“I was addicted and believe I needed it daily”.
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History of family members’ use of alcohol, other drugs, and other addictive behaviors: Describe below
“I believe my parents had some problems”.
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Have you ever received inpatient or outpatient treatment for your substance abuse or addictive behavior(s)? If so, where, when, and for how long? Reason (voluntary, mandated)? Response? Longest period of sobriety/abstinence? Relapses?: Describe below
Denied
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Check to describe consumer strengths, resources and skills related to Substance Use issues (how does the situation relate to the consumer’s condition and how will it impact her/his care and treatment?): Describe Below
“I stopped using on my own and I have been clean since that time. Howvever, dealing with my mental health and getting on medication has helped me with managing my addiction”.
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Stage of Change: Person does not wish to address at this time
MENTAL STATUS EXAM
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Physical Appearance: Appropriate
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Motor Activity/Involuntary Movements: WNL
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Behavior: Cooperative
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Speech: WNL
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Mood: WNL
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Affect: Appropriate
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Thought Process: Logical
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Thought Content: Appropriate
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Delusions: None
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Suicidal Ideation: None
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Homicidal Ideation: None
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Hallucinations/Perceptions: None
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Intelligence: Average
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Insight: Good
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Judgment: WNL
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Attention: WNL
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Orientation: Person, Place, Date, Purpose
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Memory: WNL
CLINICAL INTERPRETIVE SUM
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The Clinical Summary is based on information provided by (check all that apply): Consumer, Records
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Diagnosing AQP Assessment Summary, recommended level of care, recommendations for treatment, and criteria for transition to lower level of care and/or discharge:
Daniel is a 55 year old male who was born and raised in Washington, D.C. He disclosed his parents were around however, they did not raise him. Daniel disclosed he was raised by his step-mother. He is the oldest of 8 siblings, 2 sisters and 5 brothers. Daniel disclosed he had a good relationship with is step-mother and siblings.
Daniel was married, his wife died in 2010. He disclosed he does not have any children.
Daniel disclosed he used crack cocaine for 24 years and decided to stop using about 10 or 12 years ago. He disclosed he stopped and has not used since that day. Daniel denied going to treatment for addiction.
Daniel has an extensive mental health history. He begun services in 2014 and his most recent mental health treatment provider was Preventive Measures. Daniel disclosed being placed on medication years ago helped him to gain control over his life and manage his mental health. He stated medication has made a difference. “Since being on medication I have so much more control over my life and relationships. I have my own apartment for the past 2 years. It’s been good. I am current with all of my reponsiblities”. Daniel does not work and is not eligble for SSDI. He applied and was denied because has not put enough money into the society system for SSDI.
Daniel disclosed prior to beginning consistently to take his medication he used to experience the following symptoms, social isolation, disorganized behavior, agitation, compulsive behaviors, repetitive movements, thought disorders, anxiety, anger, feelings of detachment, elevated mood, feeling tired and hearing voices. Daniel meets the criteria for F29, Unspecified Psychotic Disorder.
Daniel is being recommended for a psychiatric assessment with medication to assist him with ongoing stablization for symptoms, individual therapy to address his underlying behavioral and cognitive challenges and community support worker services to assist him with implementing skills into his daily life functioning and supportive services for community resources including assisting him with obtaining a PCP.
Daniel will be discharged to a lower level of care once he is stablized and able function independently with managing his symptoms and being consistent with mental and physical health care.
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