Wilbur Wright College
Mental Health 229
February 29 2012
Clt is a 41 year old single African American female. She is presently unemployed and receives SSI. She is residing at the LSSI, Kenmore Center The Women's Residence. Before this she was homeless. Clt is mandated by TASC (Treat Alternatives for Safe Communities) for Tx. Clt was mandated for solicitation and possession of crack cocaine. Clt has a Dx. of Bipolar Disorder which is under control at this time with medication. Clt was admitted to detox at LSSI for alcohol, cocaine, and heroin dependence. After detox Clt was admitted to passages, which is a 28 day program, at LSSI Kenmore Center. Clt started using alcohol at the age of 9, cocaine at the age of 17, and heroin at the age of 24. Clt has a level 9th grade education. Clt has a history of physical, sexual, and emotional abuse by family members. ASAM
A) Clt is alcohol, cocaine, and heroin dependent but is currently not intoxicated and withdrawal is not imminent. Clts use of alcohol was 22oz of beer daily, one hundred dollars worth of cocaine daily, and ten dollars worth of heroin daily. Clt has had no withdrawal or periods of sobriety prior to Tx. B) There are no current health issues to report at this time C) Clt has a Dx. of Bipolar Disorder. The Dx. of Bipolar Disorder is being treated by a psychiatrist at Thresholds and is under control with the use of her present medications. Clts cognitive abilities are low and child like at times. Clts cognitive abilities may affect the course of Tx. D) Clt is in the Action stage of her recovery. She is currently sober for 37 days. Clt attends four A.A/N.A mandatory meetings a week per The Women’s Residents rules. Clt needs to find a sponsor and has 1 week to do so. Clt appears to be eager and want change in her life, although Clt has expressed “I don’t know what I like besides getting high, but I want to be different now I guess". Clt is cooperative and compliant with her Tx. plan so far. Clt is aware that if she were to go back to drinking and drugging she would “probably go back to jail and die”. E) If the Clt were to leave Tx at this time the Clt would be in imminent danger of relapse. The Clt has limited understanding of how to cope with her disorder. The Clts cognitive skills are low. The writer recommends having TBI assessed. The writer also recommends that this facility be evaluated to see if this is the best suitable place for the Clt. F) Clt is homeless and that situation does not pose a threat to the Clts safety or engagement while in Tx. Clt has nine children which are not in her custody. Clt is new to The Women’s Residence but has established a supportive rapport with the women so far. The Clt has met several of the Clts at her 28 day program, Passages. Clt states that she plans to stay at The Women’s Residence for 12 months to focus on her Tx. Clt has no family support. Clt states all of her relatives are in Mississippi and do not speak to her. Clt plans to get her GED while in Tx at The Women’s Residence. Clt and her Thresholds case worker are also inquiring about enrolling in a day program called C4 (Community Counseling Centers of Chicago) since she is not able to work and “want[s] to keep busy during the day so my mind doesn’t wander and start to want to use or get bored and stuff”. Clt is mandated by TASC but that does not seem to have a negative or positive effect of the Clts motivation or engagement in Tx. Clt states “even though I have to be here I want to be here, I guess”.
LEVEL OF CARE
Clt is currently in a level III.I Residential Tx facility. The client has been through detox and a 28 day program and the level III.I of care is appropriate at this time, even though the level of care is appropriate it is uncertain to the writer whether this particular facility, The Women’s Residence, is right for her. The Clt is childlike and lacks comprehension of what goes on during group. Group is...
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