History of methamphetamine and alcohol abuse.

Client Description:
Pat is a divorced, 34- year- old, with a two- year history of methamphetamine and alcohol abuse.
The rest of the demographics and psychosocial history are up to you.
 

Client Name: ____________
Today’s Date: ____________
I. Demographics
a. Age
b. Race/ethnicity
c. Gender
d. Housing status (stable/unstable)
II. Medical History {Subjective}
1) Reason for being here today. (Subjective report)
2) Current Symptoms (How does patient feel right now?)
3) Past medical history
a) Duration of substance use
b) Previous attempts to get help (success duration – if any)
c) Major illness or injury
d) Any chronic health issues
e) Current medications (scripted or over the counter, dosage, frequency)
f) Family Medical History
i) Major illness or injury
ii) Chronic Health issues
iii) Age/method of Death
III. Psychosocial History

1. Marital status and history
2. Sexual History and preference
3. Education
4. Occupational History
5. Socioeconomic status/financial situation
   a. Is the current illness causing financial distress?
6. Religion or spirituality
7. Family makeup
   a. “Draw” a genogram including three generations (client, parents, grandparents) [hand drawn is okay]
   b. Genogram should include mention of:
   a. Physical/mental illness
   b. Nature of relationships within family (mom, dad, sibling, etc.)
   c. Rated relationship with client (absent, poor, fair, good, excellent*)
   *subjective rating by client, [could be described by how often they speak with one another monthly. Absent = 0, Poor = 0-1, Fair = 1-2, Good = 2, Excellent = 3 or more ]
8. Supports (what positive things does the client have)
   a) Family
   b) Friends
   c) Job
   d) Treatment options

IV. Objective

1. What do you see?
   a. Body language (eye contact, motor movements)
   b. Dress
   c. Hygiene
2. What do you hear?
   a) Speech (fast, slow, stuttering)
   b) Volume (loud, soft, monotone)
   c) Word choices (“I, you, they, swearing”)
   V. Assessment
   A. What do I think is the diagnosis (reason for client to be here)?
3. Based on what evidence do I think this diagnosis is correct.
   B. What are the client’s strengths and limitations?
   a. To handle stress
   b. To find helpers
   c. To overcome difficulties
   i. “Self” awareness
   ii. Belief in self
   iii. Belief in change
   iv. Knowledge, skills, values
   d. Environmental strengths and weaknesses
   C. Suicidality Assessment
   D. What does the client need right now?
4. Based on what evidence do I think the client needs “X” right now?
   E. What supports are needed?
   F. What counseling framework/strategy/theory might best suit this client?
5. What is the evidence supporting my counseling choice?

VI. Plan

1. What is the client going to do next? (examples)
   e. Attend the next individual appointment
   f. Attend the next group session
   g. Attend a substance abuse group meeting
   h. Engage in non-use activities
2. What am I going to do next? (examples)
   a. Schedule client for individual therapy.
   b. Call and refer client for additional support services (examples)
   a. Psychiatric assessment
   b. Physical health
   c. For housing
   d. Employment
   e. Inpatient treatment

Sample Solution