He reports a history of substance abuse and trauma from finding his brother dead behind his home January 4, 2002 at 10:30am.
Mr. Williams reports going to counseling after the experiences, however discontinued outpatient services a year later. Mr. Williams reports loss of is father in 1985 on December 25 and Sister in 2006 around the same time. He expressed these losses as difficult for him. Mr. Williams states,"I have no friends anymore, I spend all my time with my family and out of my family, dead or live, I'm the most emotional one." He becomes tearful while explaining his relationships among his family member. He denies suicidal ideation, homicidal ideation, and symptoms of psychosis. Mr. Williams denies any mental health history or hospitalization for the same. He states, "Life is great." During the assessment Mr. Williams does appear guarded about reporting in detail history of drug use and stressors that may be contributing due to poor health. He reports standing up at work for 5 days a week for 12 hours and having continuous pain in both his knee. He reports no prescribed
medications.
According to Mr. Williams most recent UDS was negative for all tested drugs. HE reports a history of Heroin use, cocaine, and marijuana. He reports being 8 years clean from Heroin and other drug use. Mr. Williams expressed he has came a long way and made his family as his primary focus.
This information was reviewed with Dr. Marcus Gentry and Howard McQuirter, LCSW. They both share the disposition that the patient should be discharged pending his agreeing to follow up with outpatient services. Patient has agreed to follow up with outpatient services as recommended. The patient's family member has been contacted and made aware of the plans concerning the patient. Patient contracted for safety, was given outpatient referral information, and completed a crisis plan.
Jamaral Rease, LCSWA