Substance Abuse Clinical Assessment & Treatment Plan
Name of Client: David J
General Information:
18yo male, currently seeking therapy @ community mental health center following a traumatic accident that ended any possibility for a football career
Medical / Physical Health Status: family Dr. stated David possibly has depression as a result of the accident; still recovering from injury
Employment/Work History and Financial problems and Support Status:
HS drop out; parent’s divorces, lives with mother, received support from siblings up to 2 months after accident
Drug/Alcohol Use and Treatment History:
Pain meds for injury; takes more than prescribed; tested positive THC meth & opioids; assuming this was the clients first visit to the therapist
Family History of Alcohol/Drug Use (2 generations): none Legal Problems / Legal Status:
Illegal drug use
Family History:
Parent’s divorced; Father is African American, Mother is Hispanic, no indication of family mental health issues or substance abuse
Family / Social and Interpersonal Relations:
Mother’s favorite child. Seems to have a hard time communicating with father, father is loud and angry, client is more open when father is not around, siblings were supportive following accident, however for the last 5 weeks they have been unsupportive. Only child living a home. He has a friend that comes over 2 -3 times per week.
Use of Recreational Time:
He used to enjoy seeing seeing school friends and playing video games, but now reports having no energy for much else. Complains of lacking energy to see people.
Psychiatric/Mental Health Status and Intra-personal View:
He reports “I might as well be dead, I can’t do anything now and never will”
Self destructive behavior, eluding to loss of hope/giving up
Spirituality/Role of Religion: unknown Diagnostic Impression
AXIS I: Substance abuse related disorders. Mood disorder. Adjustment disorder. Possible Eating disorder
Description: pain med abuse
General Information:
18yo male, currently seeking therapy @ community mental health center following a traumatic accident that ended any possibility for a football career
Medical / Physical Health Status: family Dr. stated David possibly has depression as a result of the accident; still recovering from injury
Employment/Work History and Financial problems and Support Status:
HS drop out; parent’s divorces, lives with mother, received support from siblings up to 2 months after accident
Drug/Alcohol Use and Treatment History:
Pain meds for injury; takes more than prescribed; tested positive THC meth & opioids; assuming this was the clients first visit to the therapist
Family History of Alcohol/Drug Use (2 generations): none Legal Problems / Legal Status:
Illegal drug use
Family History:
Parent’s divorced; Father is African American, Mother is Hispanic, no indication of family mental health issues or substance abuse
Family / Social and Interpersonal Relations:
Mother’s favorite child. Seems to have a hard time communicating with father, father is loud and angry, client is more open when father is not around, siblings were supportive following accident, however for the last 5 weeks they have been unsupportive. Only child living a home. He has a friend that comes over 2 -3 times per week.
Use of Recreational Time:
He used to enjoy seeing seeing school friends and playing video games, but now reports having no energy for much else. Complains of lacking energy to see people.
Psychiatric/Mental Health Status and Intra-personal View:
He reports “I might as well be dead, I can’t do anything now and never will”
Self destructive behavior, eluding to loss of hope/giving up
Spirituality/Role of Religion: unknown Diagnostic Impression
AXIS I: Substance abuse related disorders. Mood disorder. Adjustment disorder. Possible Eating disorder
Description: pain med abuse