must use supporting files below to complete this assignment!!! answer questions below using the case study: !!!!Consider using the headings from the critical elements outlined above when drafting
Description I. Introduction A. Summarize the client. What is the rationale for seeking counseling?
A. Describe the problem that brought the client to treatment. i. Make sure to address any problems, issues, or challenges the client may be facing.
B. Explain the symptoms affecting the client. i. What are the behavioral symptoms? ii. What are the cognitive symptoms? iii. What are the emotional symptoms? iv. What are the physiological symptoms?
C. Identify any environmental factors that may be contributing to the client’s problem.
D. Identify any potential harmful behavior: i. Aggression ii. Harm to others iii. Harm to self iv. Criminal activity v. Impulsive behaviors vi. High-risk activity
E. Determine if the client has a family history of the diagnosis. Consider how this may affect the client. F. Use evidence-based research to support the biological factors presented in the case.
G. Outline how the client identifies him- or herself in regard to cultural characteristics. Make sure to add rationale for any answers that are not straightforward. i. What are the addressing factors?
a. Age and generational influences
b. Developmental disabilities (acquired at birth or during childhood)
c. Disabilities acquired later in life (e.g., traumatic brain injury, multiple sclerosis, stroke)
d. Religion and spirituality
e. Ethnic and racial identity
f. Socioeconomic status
g. Sexual orientation
h. Indigenous heritage
i. National origin j. Gender
H. Summarize how the client culturally identifies him- or herself.
i. With the identifiers above, how does the client culturally identify him- or herself? ii. What is the order of importance for the client? Assessment III. Co-occurring Disorders
A. Identify any co-occurring disorders. B. Describe the initial DSM diagnosis. i. What is the overall descriptor of the diagnosis? ii. What criteria must be met to meet the diagnosis? iii. Describe which client behaviors are being used to meet the diagnostic criteria.
C. Discuss the rationale behind the diagnosis. i. Identify what other diagnoses should be ruled out. Make sure to provide rationale. ii. Identify limitations with this diagnosis. Make sure to provide rationale.
D. Use evidence-based research to support your justification. IV. Addiction Assessments
A. Describe how the assessment was administered.
B. Describe the assessment scoring.
C. Summarize the assessment results.
i. How do you interpret the results? Plan V. Recommendations
A. Summarize what you recommend for this client based on the information collected.
i. Describe what you recommend for recovery.
ii. Describe what you recommend for relapse prevention.
resources you would provide to the client. Rubric Guidelines for Submission: Consider using the headings from the critical elements outlined above when drafting your DAP note, as you will do this when you submit for your final project. You may also consider using double spacing, 12-point Times New Roman font, and one-inch margins, although none of these specifications are required for the draft version. Critical Elements Pro
COU 640 Biopsychosocial Assessment
Client Name______Anessa________________________________ Chart # NA______________________
Evaluating Counselor ____stephanie Badio_________________________________ Date 12/13/20__________________
Please indicate “NA” if the question/section is not applicable to the client’s history. DO NOT LEAVE ANY SECTION/LINE BLANK.
Presenting Problem: (Include the client’s own words about why the services are needed, any referrals, and major stressors over the past six months.) Client mentioned during a dance competition she dislocated her knee. Client mentioned being prescribed with pills after injury which led to tolerance to pain killers. Client is here to obtain guidance regarding excessive amount of consuming medication. Anessa stated, she went to seek a different doctor after her previous doctor denied her.
Past Treatment History: (Include past treatment history for substance abuse AND mental health services.). Patient mentioned past history of substances when injured knee and depriving herself of food. No past mental history noted.
Family History: (Include biological family members, number of children, divorce, separations; describe what it was like growing up in this family, and include substance abuse and psychiatric history of family members.) Anessa is a middle child, she grew up with both of her parents she was an athlete who was in dance and ballet. She was very successful and won many rewards. Anessa experienced substance abuse but no psychiatric history known at this time. Both of her parents were hardworking and present in her life.
Substance Abuse Drug History: (Include top three drugs of choice.)
1.oxycotin
2.Vicodin
3.NA
Substance Type
Age of First Use
Route of Administration
Amount Used
Frequency of Use
Date of Last Use
Treatment Where/When
Alcohol
NA
NA
NA
NA
NA
NA
Cocaine
NA
NA
NA
NA
NA
NA
Marijuana
NA
NA
NA
NA
NA
NA
Heroin
NA
NA
NA
NA
NA
NA
Other Opiates
Senior year
Bi mouth
10-15pills
Twice daily
still
counseling
BZs
NA
NA
NA
NA
NA
NA
Methadone
NA
NA
NA
NA
NA
NA
Suboxone
NA
NA
NA
NA
NA
NA
Tobacco
NA
NA
NA
NA
NA
NA
List any withdrawal symptoms as reported by client (sweats, constipation, DTs, seizures, etc.):
No known symptoms reported by client at this time.
Social History
Client’s Current Life Situation: (Summarize present living arrangements and any current social supports.)
Client is currently taking 10-15 pills per day and her mother suggested to seek further treatment.
Sexual Orientation: Anessa is a female
Spiritual Beliefs: not disclose NA
Employment History
Employment: (Include longest continuous employment, type of employment, typical length of stay, present employment, and military history.) Client did not mention any employment due to injury client has not been able to work.
Education: (Note highest level of schooling completed, school performance, peer relationships, and learning problems.) client completed high school and some college. Client did not mention any close/stable relationship at this time.
Medical Health History: (Include illnesses, surgeries, medications [OTC and prescription]. Note any current medical problems, physical disabilities, and/or eating disorders. Include gynecological history and pregnancies.) Client mentioned injury in knee due to dance. Client was prescribed both Vicodin and OxyContin for the pain.
Primary Care Physician:
Name: ______________Na___________________________________________
Address: __________NA_____________________________________________
Phone: __________NA____________________ Fax: _NA______________________
Date of Last Physical Exam: _________NA___________________________
Hospital of Choice: ________NA___________________________________
Allergies: ___________no known allergies___________________________________________
Medical Medications: (Include name of medication, dose, condition it is treating, and its effectiveness.)
_______________oxycotin______________________ ______________vicodin_____________________
_____________________________________ ___________________________________
_____________________________________ ___________________________________
Mental Health/Psychiatric History:
Have you ever been treated for a psychiatric illness: Yes or No
Please explain: (Include if client has been hospitalized, seen by a mental health professional, what they were seen for, and how long they were seen.)client denied being seen for any psych issues
Any SI/HI or plan in past or present? (Please explain if “yes”) Patient denied any SI and HI
Psychiatric Medication History:
Drug Name
Prescriber
Dosage
How long have you been taking it?
Are you currently taking this medication?
Reason for this medication/diagnosis
OxyContin
NA
NA
Since highschool
yes
injury
Vicodin
NA
NA
Beginning of college
yes
injury
Legal History: (Note any charges and dates, any outstanding warrants, court dates, description of crimes, convictions, incarcerations, etc.) NA
· No legal issues
· Currently on probation
· Pending warrants
· Jail term served
· Court cases pending
· Parole
Explain with detail any and all of the above checked:
Clients Self-Assessment of Strengths:
1. _______dancer_______________________positive
2. _______active_______________________
3. ______________________________
Clients Self-Assessment of Weaknesses
1. _________tolerance
2. ability to stop_______using______________
3. ________unengaged ______________________
4. ______________________________
5.
Recommendations: (This narrative section pulls all of the information together, with a clinical opinion about what the primary issues are and what should be done to address them. Also state potential referrals to rehabilitative, IOP, and so on that are appropriate at this time.)
Clinician/Counselor Signature: _________stephanie B___________________________ Date: ___________
Clinical Director Signature: _______________________________________ Date: ___________
COU 640 ASAM Form
ASAM DIMENSIONAL SEVERITY PROFILE
ASAM Dimension
(0)
No Problem
(1)
Mild
(2)
Moderate
(3)
Substantial
(4)
Severe
Dimension One: Acute intoxication and/or withdrawal potential
X
Dimension Two: Biomedical conditions and complications
Dimension Three: Emotional, behavioral, and cognitive conditions and complications
X
Dimension Four: Readiness to change
X
Dimension Five: Relapse, continued use, or continued problem potential
X
Dimension Six: Recovery/living environment
X
Notes/Reasons:
Dimension One: Acute intoxication and/or withdrawal potential
Anessa was born in Kensington NY and was raised by both parents. Anessa is from a family of five siblings. The experience Anesssa went through while was a painful and projected her recovery time to last into her first several months while an undergrad student. Anessa was prescribed Vicodin to help with the pain. At first, She was initially provided with 60 pills to take no more than twice daily over the first month. At first, she only took one per day. However, after one particularly bad day, Anessa consumed three a night. It was then Anessa started to develop a tolerance Anessa mentioned she “loved the way she felt”.she was convinced that It helped her to focus more in her dance career. Anessa is currently experiencing severe addiction by consuming Vicodin daily after a knee injury in her past. Anessa will benefit from seeking further treatment in order to seek long term sobriety.
Dimension Two: Biomedical conditions and complications
Anessa is currently not following a healthy regiment at this time. Anessa does not have any complications with health beside her past knee injury. Anessa is unable to perform on her knee as much compared to prior surgery. Due to her ongoing habit she continued to seek more appointment with her doctor in order to support her habbit. Later, Anessa explained her medications were done early the concerning physician refused to provide her with a new prescription. Anessa will benefit from seeing a primary care doctor to evaluate further her knee and the complications of her severe substance use.
Dimension Three: Emotional, behavioral, and cognitive conditions and complications
Anessa is really torn due to lack of activity in dancing. Anessa feels like she needs more prescription and visit different doctors because they are starting to limit her ability to refill prescriptions. Anessa became irritable and started to have anxiety due to her future with dancing, Anessa continued to seek for more script to support her habits by going to different doctor.During her search she found a doctor who prescribed her with 30 OxyContin pills for the entire month. Anessa continue to seek more prescriptions, anessa noticed she used all her resources to get new prescritions.
Dimension Four: Readiness to change
Anessa is the stage of contemplation. Anessa did not identified any triggers at this time during her session. She started sleeping in late, she was absent from school a lot, isolating from family, her eating was poor, and filled with anxiety regarding her dancing career.anessa always dream of graduating from her school. Due to her mothers concern anessa pre contemplated about coming to treatment.
Dimension Five: Due to the addcition being so strong Anessa ended up relapsing. Due to her disease being so powerful she did not quit seeking form prescription to feed her habit. Anessa was able to seek She did, however, find two different doctors and was prescribed three-month supply of hydrocodone. However, it did not take long for her six-month supply of pills to complete. Anessa habbit became stronger and required more as her system became used to the pills she later started to consume 10 to 15 pills per day.
Dimension Six: Recovery/living environment
Anessa lives with her family. After her mother noticing differences in her eating and activities she suggested that she seeks further treatment for long longterm sobriety.
Reflection: Anessa will benefit from seeking further treatment and after care to sustain long-term sobriety. Anessa will benefit from supportive system to help her and hold a firm boundary.
COU 640 Case Study Client One
Anessa
Anessa was born in Kensington, New York, an affluent suburb of New York City. She is the middle child in
a family of five, born to an African American father and Hispanic mother. Her father owned his own
limousine business while her mother stayed at home with the children. The children were supported
and encouraged to explore their talents. For Anessa, this was dancing. At a young age, she enrolled in
ballet and quickly found success. In middle school, she became involved with a hip-hop dance group.
She immediately became lead, and her group became nationally awarded. In high school, she continued
with the hip-hop dance group and joined the cheerleading squad. During this time in her life, she
received many awards and was scouted by internationally acclaimed institutions including Juilliard,
which had always been her dream school. She was accepted early in her senior year and committed
herself to working even harder to make a great impression when she began school.
Unfortunately, toward the end of senior year, Anessa injured herself during a dance competition,
dislocating her knee. The experience was extremely painful and came with a projected recovery time
lasting into her first several months of college. Her doctor prescribed Vicodin to help with the pain. She
was initially provided with 60 pills to take no more than twice daily over the first month. At first, she
only took one per day. However, after one particularly bad day, she took three in a night. Anessa loved
the way she felt. It also helped her begin to dance some again. Because she could not renew her
prescription within a month, she decided to take two pills every night, which gave her a bit of a buzz and
continued to help her knee feel better than it did when she took just one. After the first month, she
convinced her doctor to refill her prescription. Again, she was given 60 pills to last the month. After a
week of continuing to take two pills per night, she then progressed to taking three. A week later, she
took four. Having done this on a daily basis, she ran out of medication early. She requested an
appointment with her doctor. They met early. After Anessa explained that she finished the pills early,
her physician became worried and refused to refill the prescription.
Frustrated and worried about her future with dancing, Anessa sought another doctor who would
prescribe her painkillers. This time, she found one who prescribed 30 OxyContin pills for the month.
Again, she ran out early, and the physician refused to renew her prescription. After trying to shop for
more doctors, she could not find anyone who would prescribe her anything as strong as OxyContin. She
did, however, find two different doctors who each prescribed her a three-month supply of hydrocodone.
This time, the six-month total supply of pills ran out in a month. Anessa was at the point of taking 10 to
15 pills per day. She was sleeping in late, missing class, withdrawing from family, barely eating, and
feeling apathetic toward her life’s dream of graduating from Juilliard. Growing increasingly concerned,
Anessa’s mother recommended that Anessa see someone.