presentation slides

Client Identifying Information

List all pertinent and known identifying information.

Name

Ray

Age

59

Gender

Male

Religion

Not disclosed

History

Describe all pertinent and known history.

Medical

No medical history is known for Ray. He does seem to have a history of drug and alcohol abuse.

Family

Ray seems to have a challenging relationship with his former partners and his Mother. Ray seems to think that the women in his life are the issue behind his misfortunes and inability to deal with stress on a healthy level.

Substance Abuse

Ray is known to drink alcohol regularly and use cocaine on the weekends. He stated that the cocaine helps his energy to complete tasks.

Developmental and Social

Ray has expressed that he believes he is not the issue and that the issue is the female persons in his life. He has a history of domestic violence with both his Mother and his wife and both women have asked him to leave their residences.

Course of Treatment

List two target behaviors and two interventions.

Target Behaviors

Drug and alcohol abuse

Continued criminal behavior

Frequency and Duration of Target Behaviors

Ray’s alcohol consumption seems to be a regular occurrence. His cocaine use has been noted to be only on the weekends.

Ray’s criminal behavior seems to be increasingly dangerous the more time goes on. Ray has an issue with rejection which has lead to his behavior becoming more criminally inclined. Ray’s alcohol use seems to be a major factor in this rising problem.

Severity and Number of Relapses

Each severity seems to increase each time Ray is arrested or charged. There has been at least 3 relapses.

3 DUI’s associated with the drug an alcohol abuse. The drinking is also a cause for the domestic violence charges against Ray’s significant other and his Mother.

Interventions

Group therapy sessions to work through the root cause of the alcohol and drug abuse. Activities involving coping mechanisms to dealing with stress and other challenging issues.

A minimum stay of 30 days in a rehabilitation center that focuses on substance abuse issues. Individual therapy sessions to work through the domestic violence offenses and other ways to deal with stress and rejection. Therapy sessions that focus on healthy relationships is also recommended.

Goals and Objectives

List two long-term goals, two short-term goals, and one objective to work towards each goal.

Long-Term Goal

To build healthy relationships, especially with the women, in his life.

Short-Term Goal

To become sober and stay away from alcohol and drugs.

Objectives

· Completing therapy sessions that focus both on personal relationships, as well as substane abuse.

· Complete, at minimum, a 30 day stay in a rehabilitation facility to progress in living a sober life.

· Practice healthy conversations with people at home and at work, focusing on what is appropriate professionally and personally.

· Attend AA and NA meetings and practice coping mechanisms.

Discharge and Termination Plans

Describe the discharge and termination plan for the client.

Discharge Plan

Upon completing and being released from the rehabilitation facility, Ray will receive a 30 day, 60 day, 90 day and 6 month review of his progress. Ray’s therapist will visit Ray at his residence or place of employment, at random, to connect with Ray and determine the following:

· Ray is still employed

· Ray has been sober

· Ray has not received any new arrests or charges

· Ray is attending mandatory meetings and making healthy progress

· Ray can pass a drug and/or alcohol test

Termination Plan

After 6 months on consecutive compliance, Ray’s care will be terminated if deemed appropriate. Ray will need to have made great progress and show true change in order to be fully terminated from care. In the event that Ray is non-compliant within the 6 month period and beyond, he will be admitted into the criminal justice system accordingly.