1 8-1 Final Project Part II Submission: Clinical Documentation Allen Richard Southern New Hampshire University HSE 350-Q7204 Substance Use: From Screening Monica A. Farrar, LMHC, CRC CASAC (NY) LPC, CSAC (VA), LPC (AZ) April 28, 2024 Biopsychosocial Assessment
2 Client Name: Joe Smith Evaluating Counselor: Mike Lococo Date: 3/31/24 Instructions: Use this document to record the client interview. Insert "NA" if the question/section is not applicable to the client's history. DO NOT LEAVE ANY SECTION/LINE BLANK. Space expands as you type. Presenting Problem: (Include the client's own words about why the services are needed, any referrals, and major stressors over the past six months. What are the positive and negative consequences of not using? Include client's current primary drug use with age of first use, pattern, duration, and intensity.) Joe presents as a single male with a history of substance abuse. Joe states, "My life is unmanageable. I need to get myself together so I can have a normal life." He also states, "Drugs are my weakness." Joe reports being unemployed and homeless. He also has significant criminal justice involvement. Joe is currently under probation supervision for committing check fraud. He denies having biomedical concerns, medical coverage, or a primary care provider. Joe reports engaging in unprotected sex with multiple partners. He denies receiving mental health services. Joe reports a limited support system in the LGBTQ community but does not identify as being gay. He lacks other forms of sober support. Joe's primary substance of use is heroin. He began using it at the age of 21. Joe currently uses 8-10 bags daily intravenously. He denies sharing needles. Past Treatment History: (Include past treatment history for substance abuse AND mental health services.) Joe reports multiple substance use disorder services, including individual sessions and intensive outpatient treatments. He also reports he has attended Narcotics Anonymous meetings in the past. Joe denies any involvement with a mental health professional. Family History: (Include biological family members, number of children, divorce, and separations. Describe what it was like growing up in this family, and include substance abuse and psychiatric history of family members.) Joe reports growing up in an antagonistic family environment. His immediate family consists of his father (deceased), his mother, and a sister. Joe reports being physically and mentally abused by his father. He reports sexual abuse by his uncle at age 14. Joe reports his father had a history of alcohol and drug use. His mother is a daily drinker and drinks "all morning long and into the evening." He is unsure of his sister's drug and alcohol use. Joe reports he has not spoken to his family in seven years. Substance Use History Top three drugs of choice: Heroin Cocaine (crack) Tobacco Substanc e Type Age of Route of Administra Amou nt Frequen cy of Date of Last Treatment Where/When
First Use Alcohol 14 Oral Cocaine 1fi Marijuana 16 Smoking Heroin 21 Intravenous 8-10 bags Other Opiates 21 BZs N/A N/A Methadon e N/A N/A Suboxone N/A tion Insufflation/ Smoking