The counselor met with client for her scheduled assessment. CPS caseworker Margie Jones referred the client because of testing positive for illicit substance. The client is a 25 years old African American woman. She is mother of five children a set of twins and one has recently died. The mother reports the baby was laying on her chest and got tangle in the cover and died. She became tearful when talking about this. The mother reports she has been distraught and began using illicit substances to cope with her grief. The client reports being recently prescribed an anti-depressive to address her depression. She reports one prior suicide attempt in 2013 by overdoing on pills. The client reports being sexually assault at the age on 12. She reports
receiving a high school diploma in 2016 and recently got a job at Amazon. Sher reports having a rocky relationship with her mother. The client reports onset use of alcohol at the age of 21 and drinks mixed drink on the 2-3 times a month. She also reports using Cannabis with the onset at age 15 and smoking a couple blunt daily. She reports the lasts use was in January 2018, however is smoking synthetic marijuana and last used on April 14, 2018. The client also reports using Xanax 2 tab previously. The client denies any HI/SI at the time of her session. The client was oriented time three. She was cooperative throughout the session. The client seems to be emotional when speaking about the loss of her baby. She meets the DSM 5 criteria for F12.20 Alcohol Use Disorder Moderate and F12.20 Cannabis Use Disorder Moderate as evidenced by her substance use was exacerbated. The client use resulting in failure to meet major obligations. The recurrent substance use has place her and the children in a situation in which it is physically hazardous. She has given up important social, occupational, or recreational activities are given up or reduced because of substance us. She is often taking in larger amounts or over a longer period than was intended. She spent a great deal of time in activities necessary to obtain the substance or recover from its effects. P) Recommendation: The client needs of twelve hours of individual substance use disorder to address life skills, relapse prevention the importance of health social support systems. She also needs to establish adequate housing for family reunification. The skills to addresses grief and loss without substance use.
Rosa Lee Cunningham is a 52-year old African American female. She is 5-foot-1-inch, 145 pounds. Rosa Lee is married however, is living separately from her husband. She has eight adult children, Bobby, Richard, Ronnie, Donna (Patty), Alvin, Eric, Donald (Ducky) and one child who name she did not disclose. She bore her eldest child at age fourteen and six different men fathered her children. At Rosa Lee’s recent hospital admission to Howard University Hospital emergency room blood test revealed she is still using heroin. Though Rosa Lee recently enrolled in a drug-treatment program it does not appear that she has any intention on ending her drug usage. When asked why she no longer uses heroin she stated she doesn’t always have the resources to support her addiction. Rosa Lee is unemployed and receiving very little in government assistance. She appears to
MSW intern spoke with ct’s mother via telephone to gather additional information for ct’s initial assessment. MSW intern obtained verbal consent to disclose information to CSW Talin Boghossian for the purpose of gathering information to conceptualize the case and guide treatment (Release of Information to be obtained and filed in ct’s chart during next face to face session). MSW intern inquired about ct’s medical hx, trauma hx/trauma exposure to which mo expressed concern ct may be vulnerable to victimization and was exposed to DV one time when ct was 3-4 years old; and child abuse/protective service information to which mo reported police intervention on 1/31/16. MSW intern gathered information regarding ct’s developmental hx, developmental
The reporting party (RP) was informed by foster child Kahryn current foster mother Shaquita at (909) 714-7859 that he had a scratch on his nose, scratches on his face and a “knot on his face. Shaquita was informed that the child had fallen. The RP had a visit with Kahryn on 5/28/16 and observed some was wrong with him. The RP stated someone named Roy (last name unknown) what to take Kahryn to the hospital during the visit (Roy's relationship to Kahryn unknown). According to the RP, Roy contacted the CFS Social Worker Tamzida Shams the same day and informed the current foster mother he had received permission to take the child to the hospital. Shaquita stated she didn't know anything about that and explained to Roy that she would need to contact her FFA Social Worker Anna (last name unknown).
Per mental health records (2016), the claimant had a significant history of mental illness, including depression and anxiety. Additionally, he had a history of drug, alcohol, and tobacco abuse. He received inpatient psychiatric treatment multiple times, mostly because of suicidal ideation with plan and intent. He also received ongoing outpatient treatment.
Behavior Modification Worker, BMOD, arrived to Client, Quinton Garrett’s, school to observe and improve client’s behavior. The day began with a call from client’s school nurse with some concerns and issues she’s had with client. Upon arrival BMOD met with the school nurse to discuss her concerns. The nurse then states that for the past few Fridays client says that he has taken his medicine before he arrives to school. The nurse could not reach Mom by telephone for confirmation. BMOD informs nurse that client is a habitual liar and to question everything especially when medicine is concerned, but would confirm the validity of client’s compliance with Mom. The school nurse also says client has a bad habit of hiding when she is interacting with
The client is currently dealing with many circumstances that seem to take priority over his recovery. He expressed his concerns about his legal issues and his fear of receiving an extensive prison sentence. Christopher has also not dealt with the issues that he harbors due to the sexual abuse he endured from his father. He has a rocky relationship with his biological father because his father shows no remorse for what he did to him. It is apparent that Christopher still yearns for the love and attention that he never received from his father. He has a good relationship with his mother and stepfather, his stepfather raised him since he was four years old. His drug use and criminal behavior have caused a rift in the relationships with the people who have been there for him. Christopher doesn’t feel that he has a problem with drugs even though he voluntarily admitted
Counselor met with Pt. to conduct his monthly individual session. Counselor started the session greeting Pt. inquiring how things have been going since the last session and whether the patient has used any drugs or alcohol. Pt. disclosed to counselor that he is doing his best to maintain financially, as well as, to stay clean. Pt. reported that he still using illicit drugs, however, he stopped heroin use. Pt. extensively shared with counselor about how he is trying to stay strong due to his son not living with him and he is under the care of grandparent. Pt. further disclosed that his father-in-law has been refusing to give him his son and he called the cops on him. Pt. informed this writer that he recently got charged with harassment because his father in law reported the Mr. Weedon threatened him over the phone. Pt.
On 5/2/17 a separate ISP meeting was completed (because of PFA) with Melissa Carson. Caseworker, Kenesha Grant and Ondria Moore, spoke with mother regarding why DHR is involved. According to Mrs. Carson, the reason for DHR involvement is due to her Ex-husband-Philip’s domestic incident that exposed their children (Penelope, Judea and Jianna) to a safety threat. Mrs. Carson provided worker copy of the children Birth cert, SSN, PFA and custody hearing document. According to her, Mr. Miller and he were married in 2006 and divorce in 2016 Mrs. Carson, told worker Mr. Miller has always been abusive physically, emotionally and verbally towards her and his current wife Lena Miller. She said that Lena Miller is the person is force to take care of
Child Protective Services is a government agency that who’s job is to protect the children from an abusive and neglected homes. Child protective services takes custody of the children for their safety.
The client Pam has been brought to counseling by a friend who believes she needs to talk to someone professionally. Pam appears disheveled and unable to communicate clearly with the counselor. Pam is extremely energetic and is constantly moving around in the chair. Pam explains she has not slept in four or five days and is very tired. Pam is too tired to sleep and feels she has too many thoughts on her mind. She believes she is chosen to show her talents and does not have any suicidal thoughts. During the counseling session Pam seemed to be in a manic stage. Although she is not depressed or expressing suicidal thoughts currently, there is no evidence she wont have these symptoms at another time (Cengage Learning, 2009). The ACA
On the event date above, an office visit was scheduled with Mrs. Falletta. During the course of the session it was supposed to be based on completing the intake; however, Mrs. Falletta appeared to be emotional detailing her marital problem as her husband is part of a Mafia, he’s cheater, prior substance abuse, and other children out of wedlock. Mrs. Falletta is fearful for her safety, at which this writer discussed safety plan. This writer provided Mrs. Falletta with information about Family Justice Center, PATH shelter system, and the number to Hope. Mrs. Falletta reports she tried the PATH shelter, but it was not successful. She also tried the Family Justice Center and again, no success. According to Mrs. Falletta, Mr. Falletta works as
The client is a 24 year old African American woman who describes her overall life as overwhelming. She is currently in a graduate program in mental health counseling; she is almost nine months pregnant and is having labor induced on Monday, February 22, 2016. She has also expressed concern and apprehension for an upcoming visit from her significant-other’s mother. Although she appreciates her support system, she has communicated concerns about wanting to control pending situations around her. Her prevailing motives for seeking counseling at this time are that she does not want to be a burden to her fellow students and family with her personal demands, plus she feels that she has a lot going on
Ms. Brooks is a 14 year old female who presented to the ED via LEO after an altercation with family members. It should be noted Ms. Brooks can on a voluntary commitment. Before the assessment Officer InGold was contacted for information. Officer InGold reports he received a call for an altercation at American RoadHouse for a female who was screaming at her mother, which turned into a physical altercation. He reports Ms. Brooks was severally anger an expressed she wanted to kill herself and that she has been wanting to do so for a while. At the time of the assessment Ms. Brooks reporting having a history of child abuse witnessing domestic violence by her father. She reports a history of depression and anxiety. Ms. Brooks currently denies suicidal ideation, homicidal ideation and having any visual or auditory hallucinations. Ms. Brooks does not appear to be exhibiting signs of agitation, aggression, or responding to internal stimuli. Ms. Brooks
The writer met with 28 y/o AAM brought to Beaumont Dearborn by DPD due to argument with is father over his phone. The consumer rport getting into a verbal argument with his father because someone stole his phone. The consumer report having anxiety, verbal assualt toward his father, and the desire to improve on his current situation. The consumer denied having any deulsion, auditory/visual hallucination, suicidal/homicidal ideation, no poor impulse control, no self injury, on impaired judgment, and no insight into the need for treatment. The consumer present blunt affect, paranoid, delusion, disorganized thought, rapid speech, lack insight into the need for treatment and unable to stay focus during his assessment. The consumer was also vague
D-This writer met with the patient as she was placed on HOLD. The patient apologized for meeting with this writer late due to a bit of a traffic. The patient began to get emotional during the session while discussing her commitment to her recovery process and how much of a change of not using has impacted her life. The patient says, " Charlene, girl,....When I stopped using, It had open my eyes. My children are doing great and my husband are getting along great. My husband is so proud of me, Charlene. I did a lot of fucked up shit in my relationship and this man, stood by my side through it all. I am so grateful. I always love coming here, especially talking you, girlfriend." There was joy and laughter during the counseling session. This writer provided support and motivation to the patient recovery process. Furthermore, the patient stated that she hasn't been using since last UDS result and ensure that her next UDS result for the month of May would be negative. The patient is also aware during the discussion of the risk of not producing a negative and being consistent with it. This writer discussed about treatment violation Step 1 next month, not to deter the patient, but more so of a wake up call if a negative is not produced. This writer also discussed options about seeking higher level of care such as an IOP, at which the patient decline the suggestion because she prefer attending group's at this