Client is a 23 year old African American female with 11 years of formal Education. Client was referred to address her opiate dependency. Client reported being arrested August 8, 2017 for second degree assault with deadly weapon with intent to injure. Client reported that she was sentenced to Pretrial. Client stated that her court date is September the 11, 2017.

During intake client stated she had been using Percocet since the age 16 three or more times daily. Client states that she has been drinking since the age of 13 and she currently drinks one half gallon of alcohol daily. Client was referred to Crisis Response August 28, 2017 for seven day detox. Client was both detoxified for alcohol and opiates both. Client reported smoking cigarettes since the age of 7 she currently smokes one pack daily. Client has interest in quitting smoking cigarettes information on smoking cessation classes was given.

Client states that she can’t recall her last physical but states she has been diagnosed with anemia. Client stated that she is not taking any prescribed medication except for12 mg. of suboxone prescribed by Crisis Response. Client stated that her medical problems will not interfere with her treatment. Client stated that she does not have medical insurance and is not linked to services. Client was referred to medical staff for evaluation and referral for medical services. Client was given the physical pain screening and based on the assessment the client experiences a rating of 0 on a scale of zero thru ten (ten being the high number to be assessed for pain). Client was given the HIV/AIDS Risk Assessment. Client states that she had a TB test and HIV test in the last month and both test were negative.

Client reports being diagnosed with Post Traumatic Stress Disorder and Anxiety Disorder in her teenage years. Client reported not taking medication for mental health because she is not linked to services. Client states that she has not seen a therapist since she was a teenager. Client mental health screening and suicide risk assessment scores for Anxiety (5) and Trauma (6) were elevated so her case was discussed with the Clinical Director. Based on the Clinical Director and my assessment it was determined that the client will be evaluated further by the mental heath therapist and be placed in our IDDT protocol for co-occurring diagnosis.

Client reports that she currently resides with a friend that help with paying bills. Client reported that she is divorced with two children. Client reported that she raised herself because her parents both had a drinking problem. When asked about her relationship with parents she stated it was strained because of addiction. Client reports she has a long distant relationship with her one sibling. Client reported no history or substance abuse or neglect in her family. Client was given the Family Assessment Tool and it was determined that she did not have a good a good up bringing and her family was not supportive. The ASI was completed and all requirements of the program were read, explained, and signed.

Client was given a medical and clinical assessment. Client met the DSM-IV-TR criteria for heroin dependency and nicotine dependency and the ASAM Criteria for the Intensive Outpatient level of care. Client was assessed and admitted September 4, 2017. Client was given a schedule to attend 4 two hour group therapy sessions and 1 one hour individual session weekly. Client will submit random urinalysis upon request. Client is being admitted into our IDDT Program where she will receive co-occurring group sessions and individual mental health sessions.

At present, client’s needs are as follow: (1) to be educated on opiate dependency and alcohol dependency, (2) develop relapse prevention skills, (3) attend group therapy sessions and individual counseling sessions as required ,(4) develop a positive support network within her community and (5) address mental health issue while participating in Integrated Duel Diagnosis. Client strength is she is motivated to engage in treatment in order to improve the quality of life that has been impacted by her addiction.

Multi- Axial Assessment

Axis I 304.00 Opioid Dependency, 303.9 Alcohol Dependency, 305.1 Nicotine

Dependency Depression and Post Traumatic Stress Disorder and Anxiety

Disorder

Axis II 799.9 Deferred

Axis III Anemia

Axis IV Lack of Positive Support Network, Lack of Employment, Financial Support,

Legal Problems

Axis V GAF 50

Counselors Signature Date

Supervisors Signature