This is sample treatment plan and assessment based on a fictional case study.
The purpose of this interview was to assess the patient 's need for addiction treatment by reviewing patient 's present and previous usage history, emotional and behavioral stability, and potential for relapse, environment, pertinent medical conditions, and willingness or desire for treatment. An interview and medical records gathered this data.
Name: Stan Jacobson Date: May 6, 2005
Age: 25 years old Gender: Male
Ethic background: Caucasian Birth date: February 3, 1980
Residence: 161 N. Ray St. Minneapolis, MN Referral: Court ordered
The client is being assessed today due to a conviction of driving under the influence. The ruling judge ordered the client to obtain professional help with addiction problems. This assessment will determine level of recommended treatment, if any treatment is needed.
DIMENSION 1: ACUTE INTOXICATION/ WITHDRAWAL
Client 's usage history began when client was approximately 15 years old (usage is approximately 10 years). Client states the he is currently a 'heavy ' drinker who frequently drinks until drunk. Client states that he uses alcohol 5-7 days a week, with consumption ranging from 6-24 beers per occasion. Client also has a history of heavy drug use. Client states that alcohol is the present drug of choice, but admits to occasional marijuana and cocaine use. Marijuana usage is approximately once a month, cocaine use is approximately 3-4 times a year, and amounts used are unknown. Client is a 2 pack a day tobacco smoker. Because of client 's alcohol use, client was recently convicted of driving under the influence of alcohol and ordered to seek help. Client was placed in a youth detention center in high school for theft and ultimately was expelled from regular school, finishing his education at a continuation high school. Client reports significant social and relationship difficulties. Client presents with no history of alcohol, marijuana, or cocaine withdrawal symptoms and does not appear to be experiencing symptoms currently.
Name: Stan Jacobson Date: May 6, 2005
Age: 25 years old Gender: Male
Ethic background: Caucasian Birth date: February 3, 1980
Residence: 161 N. Ray St. Minneapolis, MN Referral: Court ordered
The client is being assessed today due to a conviction of driving under the influence. The ruling judge ordered the client to obtain professional help with addiction problems. This assessment will determine level of recommended treatment, if any treatment is needed.
DIMENSION 1: ACUTE INTOXICATION/ WITHDRAWAL
Client 's usage history began when client was approximately 15 years old (usage is approximately 10 years). Client states the he is currently a 'heavy ' drinker who frequently drinks until drunk. Client states that he uses alcohol 5-7 days a week, with consumption ranging from 6-24 beers per occasion. Client also has a history of heavy drug use. Client states that alcohol is the present drug of choice, but admits to occasional marijuana and cocaine use. Marijuana usage is approximately once a month, cocaine use is approximately 3-4 times a year, and amounts used are unknown. Client is a 2 pack a day tobacco smoker. Because of client 's alcohol use, client was recently convicted of driving under the influence of alcohol and ordered to seek help. Client was placed in a youth detention center in high school for theft and ultimately was expelled from regular school, finishing his education at a continuation high school. Client reports significant social and relationship difficulties. Client presents with no history of alcohol, marijuana, or cocaine withdrawal symptoms and does not appear to be experiencing symptoms currently.