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This Is Sample Treatment Plan And Assessment Based On A Fictional Case Study.

1031 words - 4 pages

The purpose of this interview was to assess the patient's need for addiction treatment by reviewing patient's present and previous usage history, emotional and behavioral stability, and potential for relapse, environment, pertinent medical conditions, and willingness or desire for treatment. An interview and medical records gathered this data.Name: Stan Jacobson Date: May 6, 2005Age: 25 years old Gender: MaleEthic background: Caucasian Birth date: February 3, 1980Residence: 161 N. Ray St. Minneapolis, MN Referral: Court orderedThe client is being assessed today due to a conviction of driving under the influence. The ruling judge ordered the client to obtain professional help with addiction problems. This assessment will determine level of recommended treatment, if any treatment is needed.DIMENSION 1: ACUTE INTOXICATION/ WITHDRAWALClient's usage history began when client was approximately 15 years old (usage is approximately 10 years). Client states the he is currently a 'heavy' drinker who frequently drinks until drunk. Client states that he uses alcohol 5-7 days a week, with consumption ranging from 6-24 beers per occasion. Client also has a history of heavy drug use. Client states that alcohol is the present drug of choice, but admits to occasional marijuana and cocaine use. Marijuana usage is approximately once a month, cocaine use is approximately 3-4 times a year, and amounts used are unknown. Client is a 2 pack a day tobacco smoker. Because of client's alcohol use, client was recently convicted of driving under the influence of alcohol and ordered to seek help. Client was placed in a youth detention center in high school for theft and ultimately was expelled from regular school, finishing his education at a continuation high school. Client reports significant social and relationship difficulties. Client presents with no history of alcohol, marijuana, or cocaine withdrawal symptoms and does not appear to be experiencing symptoms currently. Client states that he is not currently experiencing nicotine withdrawal, however there is potential for nicotine withdrawalRisk level: Due to lack of significant and harmful withdrawal symptoms, risk level is 0.DIMENSION 2: BIOMEDICAL CONDITIONSClient states he has a history of impotence (medically untreated). Client does not have any known medical conditions that would prevent recovery. Client has no known allergies, no currently prescribed medications, and smokes tobacco daily.Risk level: Due to lack of interfering medical conditions, risk level is 0.DIMENSION 3: EMOTIONAL/ BEHAVIORAL CONDITIONSClient states that there is no known history of previous diagnosis or treatment for psychological problems, nor any current or previous use of psychiatric medications. Presently, there has been no known psychological testing or psychological consultations. Client complains of depression, anxiety, thoughts of suicide, low self-esteem/ self-concept, and anger. Client states that he attempted suicide a couple of...

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