Name of Client: David J
Basic Information:
18yo guy, currently looking for therapy snabel-a community mental health middle following a traumatic accident that ended any possibility for a football profession
Medical / Physical Wellness Status:
family Doctor stated David possibly features depression due to the incident; still coping with injury
Employment/Work History and Economical problems and Support Position: HS drop-out; parent’s splitting of marriages, lives with mother, received support by siblings up to 2 months after incident
Drug/Alcohol Work with and Treatment History:
Pain medications for injury; takes much more than prescribed; tested positive THC meth & opioids; if, perhaps this was the clients initially visit to the therapist
Genealogy of Alcohol/Drug Use (2 generations):
none
Legal Problems / Legal Position:
Illegitimate drug make use of
Family History:
Parent’s single; Father is definitely African American, Mother is Mexican, no signal of family mental medical issues or substance abuse
Family / Social and Interpersonal Relationships:
Single mother’s favorite child. Seems to have a difficult time communicating with father, father is definitely loud and angry, customer is more open up when father is certainly not around, brothers and sisters were supporting following incident, however for the very last 5 several weeks they have been unsupportive.
Simply child living a house. He contains a friend that comes more than 2 -3 times a week.
Use of Leisure Time:
He utilized to enjoy finding seeing institution friends and playing game titles, but now studies having not any energy intended for much more. Complains of lacking strength to see persons.
Psychiatric/Mental Wellness Status and Intra-personal Watch:
This individual reports “I might as well become dead, My spouse and i can’t do anything now without will Do it yourself destructive habit, eluding to loss of hope/giving up
Spirituality/Role of Religion:
unknown
Diagnostic Impression
AXIS My spouse and i: Substance abuse related disorders. Feelings disorder. Adjustment disorder. Feasible Eating disorder
Information: pain med abuse and testing great via urinalysis for THC, opioids, & meth. Mood swings ” one moment he is thrilled and buzzin & in some hours or next day he may complain of devoid of any energy or pursuits. Adjustment ” he sensed that the car accident was the end of virtually any opportunity for a professional career, feeling ugly, lack of passion for getting healthful. (Possible fat loss)
AXIS II: N/A
Description: N/A
AXIS 3: Leg injury-compound fracture remaining leg over knee 10 months before *Referred by primary treatment doctor
AXIS IV: Principal support group, educational problems. Complications related to cultural environment, different psychosocial and environmental complications
AXIS Sixth is v: GAF: forty seven
Crisis managing and involvement strategies:
drug use ” talk about it, discuss it; advise rehabilitation for drug work with suicidal ideation- address problem with client
Treatment solution:
A. Explanation of assumptive models utilized:
1 . Short term desired goals:
i. Relief of symptoms of major depression
2. Restore relationships with past friends
iii. Locate at least one fresh activates that evoke positive feelings 4. Develop simply no self harm contract
v. David will survey no taking once life ideation to get 4 consecutive weeks vi. Learn dealing skills to work on adapt and adapt to injury vii. Learn to determine maladaptive, mental poison and how to replce them with more positive adaptive thoughts which will be scored by displaying these skills during therapy classes and by research assignments intended for 4 consecutive weeks
installment payments on your Long term desired goals:
my spouse and i. Explore education options
ii. Explore consistent specific therapy
iii. Drug abuse Recovery, Group therapy
iv. Increase sense of self and confidence
v. Stable support system
vi. Reduce symptons of depressive disorder
B. Model of individual therapy: (motivational selecting, group therapy, fam remedy, etc) 1 . Individual remedy twice every week for 4 weeks the once per week for 6 weeks right up until symptoms possess approved pending other requirements and or constraints (insurance, therapies facility requirements, etc . ) *Counselor and client will consistently determine the future course of the sessions. 2 . Person Centered/Humanistic way (he made available with woman therapists easily)
C. Adjunctive referrals:
1 . Therapist will refer client to 12 stage program (Narcotics anonymous, amazingly meth unknown, marijuana anonymous) and/or detoxification facility
D. Specific surgery for specific presenting problems:
1 ) Medication management-Reevaluate prescription medications with medical doctor 2 . Individual therapy-explore, process, & resolve depressive emotions and coping expertise. 3. Friends and family therapy-explore & help family to understand aspect, negative patterns & problems in the family members structure. Motivate family to master & employ communication and conflict resolution expertise. 4. Physical therapy as a discomfort reduction to lessen pain medications 5. Not any self-harm agreement
5. Enhance parent’s and sibling’s capacity to support & encourage
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