Week 7 and Week 9

Client Name

Presenting Concern: Why did the client come to treatment and counseling?

Case Conceptualization

Addiction History

· Substance(s) used and/or any addictive behaviors identified

· Age of first use

· Family history of addiction (chemical and/or behavioral)

· Progression of use to current stage

· Average frequency and amount over last six months

· Other signs and symptoms of addictive use (e.g., blackouts, increased tolerance over time, physical withdrawals if use stopped)

· Negative consequences experienced due to use

· Previous attempts to stop on own and/or treatment history

· Level of denial of problem (e.g., none, mild, moderate, severe)

· Level of motivation to change on admission (i.e., low, moderate, high)

Co-Occurring Disorders and Diagnosis

· Any other current or past mental disorder or mental health problem

· Signs, symptoms, course of disorder, and other pertinent information necessary to plan treatment

· History of treatment or counseling

Medical History

· Pertinent current or past medical history related to or affected by addiction

· Current medications (e.g., psychotropic and/or prescribed addictive medications)

Educational/Vocational History

· Education

· Work/career history including problems related to addiction

· Current financial status

Legal History

· Current or past legal problems

· Current status of any existing legal problems

Social/Cultural Status

· Socioeconomic status

· Any cultural/ethnic factors influencing addiction and recovery

· Social/leisure activities

Family/Relationship Status

· Composition of immediate family

· Description of roles identified for each family member

· An explanation of the potential impacts of these roles on family members.

· Include family in client’s treatment plan and a minimum of two resources that would be useful to them

Assessment:

· Description of how initial screening was conducted to validate the existence of a problem and make initial treatment recommendations. Include how information was gathered (e.g., verbal clinical interview, paper-and-pencil assessment instrument) and sources of information (e.g., client, family members).

· Overview of ongoing assessment process to evaluate severity of the addiction, rule out the co-existence of other relevant problems, assist in treatment planning, and monitor progress (e.g., continued more detailed interviews with client and family members, observation, standardized assessment instruments).

Model of Addiction and Case Management (Refer to coursework submitted Weeks 1 and 4. Provide a summary)

· Model(s) of addiction used to plan treatment approach. Rationale for use and strengths and weaknesses of chosen model(s)

· Model(s) of treatment used. Rationale for use and strengths and weaknesses of chosen model(s)

· Include benefits of choosing evidence-based practice as model of treatment

· Model(s) of case management used. Rationale for use and strengths and weaknesses of chosen model(s)

· Include benefits of choosing evidence-based practice as model of case management

The Role of Spirituality

· Describe how spirituality could be an important factor in client’s recovery

· Ways in which client’s spiritual needs might be addressed through case management referrals to community 12-step support groups or other spiritual resources

Course of Treatment

Current level of treatment (refer to ASAM Resource p. 13–14).

· Dimension 1:

· Dimension 2:

· Dimension 3:

· Dimension 4:

· Dimension 5:

Projected level(s) of treatment after discharge from residential treatment over the next 12 months and an explanation of why this level(s) would be effective

· Projected levels of treatment over next 12 months

· Prognosis for response to treatment over next 12 months

Discharge Plan

· Summary of treatment recommendations over next 12 months (as reflected in treatment plan)

Relapse Prevention and Continuum of Care:

· Describe relapse prevention needs and challenges for the client. Discuss the continuum of care plan and recommendations for the client.

Ethical Considerations: Note any ethical considerations or challenges associated with this case.

Reflection and Professional Development Plan

· Provide a reflection about what you learned from this case and how you will apply your knowledge to future practice.

· What are your ethical responsibilities in working with addictions and cultural responsiveness? Support your points with specific ethical standards and a plan for ongoing ethical and cultural responsiveness.

· How will you keep up with trends related to best practices, integrating telehealth counseling, and any changes to laws or ethical standards? Support your points with the course learning resources and a specific plan to address these factors. Finally, discuss your personal and professional strengths that will support your practices and a plan for ongoing self-care.

Support your points with specific references to the Learning Resources and any additional sources you identify, using both in-text citations and references. It is strongly recommended that you include proper APA format and citations