8-1 Final Project Part II Submission: Clinical Documentation
8-1 Final Project Part II Submission: Clinical Documentation
HSE-350 Substance Use: From Screening
Southern New Hampshire University
Wanda J. Prince
February 24, 2022
8-1 Final Project Part II Submission: Clinical Documentation
HSE 350 Biopsychosocial Assessment and Diagnostic Interpretation
Biopsychosocial Assessment
Client Name: Joe Smith
Evaluating Counselor: Wanda Prince
Date: January 28, 2022
Instructions: Use this document to record the client interview. Insert "NA" if the guestion/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.)
Client is a 30-year-old Caucasian male who is self-referred for treatment. He has stated that this is his first time entering into residential treatment however he has "tried several outpatient counseling and intensive outpatient
treatment is, "My life is unmanageable. I need to get myself together so I can have a normal life." Mr. Smith states that it is his hope to get his life together and have a normal life which includes getting married, having kids, and holding a steady job. He also states: "I just want to find love, be loved, and give love," "I know I've screwed up my life. Drugs are my weakness, I can be lazy, and I'm hard on myself. But I know there's a good person inside of me. I can be great with people, resourceful, and loving. I just need a chance at sobriety." Mr. Smith also reports "I think there's a problem with living your life drugged all the time. Just not sure how to stop it."
Past Treatment History: (Include past treatment history for substance abuse AND mental health services.)
Mr. Smith has reported that he has tried outpatient counseling and intensive outpatient programs multiple
the programs he has been through in the past. Mr. Smith also reports having had involvement in NA in the past.
8-1 Final Project Part II Submission: Clinical Documentation
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.)
The information that was given about Mr. Smith's family is as follows: "My family was messed up, my old man beat me up, my mother watched, and my older sister just kept quiet so that she could be spared." Mr. Smith reports being sexually abused by an uncle that was living with his family at the age of 14. He reports that his father died when he was 16 from liver failure. About his father Mr. Smith states: ""The old man died from liver
Smith's mother and sister live in the area, and he reports that his mother is "most likely an alcoholic tha