Client reported using heroin on and off in the last past month. The client also reported using clean needles to shoot up heroin and spending $30 a week on his drug usage. The client reported smoking crack cocaine one week ago. VA documentation shows the client being opiate dependent with history of meth and cocaine use.
The client reported using heroin to cope with physical pain related to his knee and back. The client also reported using when he is bored and has nothing to do. The client will like to cut back on his heroin use and be sober by the time he finds an apartment.
The client reported that staying busy helps him with sobriety. The client reported his plan to distance himself from bad influences in order to be less tempted to …show more content…
The client continues to refuse MH services through OPT at this time. The client attends on and off a PTSD support group while in the program. The client reported having PTSD, secondary to his time in the Army (non-combat). VA records show a Dx for PTSD and a medication list which includes, Sertraline and Sertraline HCL, as well as Methadone. The client reported being medication compliant. Client denied any S/I or H/I.
The client will like to seek treatment for his PTSD symptoms. The client reported being open to MH services through another source other than his OTP.
The client reported his plan to continue asking his PCP for a new referral for MH services. The client reported his intent to continue attending the weekly PTSD support groups while in the …show more content…
Physical health
The client reported his skin condition to have improved a lot within the last month. The client reported seeing his PCP on 2/5 and being referred to surgery for his knee and back. The client is currently waiting for a follow-up call with the WLA VA orthopedic surgery center, in order to find out a surgery date. The client reported dealing with knee and back pain for quite some time.
The client stated that he wishes that surgery will him walk better and help him with knee pain. The client stated his desire to be able to do more activities after his knee surgery.
The client reported his intentions to contact the WLA VA orthopedic surgery center in order to find out more information about his surgery. The client also reported that will attend all of his appointment before and after his surgery.
Relationship
The client reported that he has no relationship goals at this time.
Benefits
The client has no employment goals at this time. The client is rated at 50% service connection for hearing loss. The client receives $836 a month from the VA. The client also received $64 a month from