Instructions: Please demonstrate what you have learned throughout this course. This assignment is designed to assess the competencies (skills) that you have acquired while taking this class. We are still working with our patient, Mr. Michael Doe. Please read the information denoted below.
Michael Doe has been accepted into the ABC Treatment Program. Please ensure that these activities are reflected in his case file (and case notes). Once, you have completed all of the steps listed below, please create a PDF file to upload the case file into the Assignment Depository. Ensure that your documents are numerical order according to the steps below. For example, the intake documents should be first, then, the assessment instruments and results, then, the treatment plan, etc. Provide page numbers on your documents. Provide dates all case notes. You will find documents below to help work through this assignment. Please include this information on all of the documents to be uploaded into one PDF file.
M. Doe DOB: 7/21/77 Case Number: 001 SSN#: 0342
Please open a case file for Mr. Doe by completing the all intake documents. Ensure that you and the client sign all forms.
Administer the Biopsychosocial Assessment (ASI Instrument) (completed, but upload it again with your case file) depression and anxiety screenings and Mental Status Examination to Mr. Doe. Write a treatment note about administering the instruments to Mr. Doe and the results of your findings.
After you administer the instruments to Mr. Doe, develop a treatment plan (completed before but note that you will modify the document (read below), then upload it again with the case file) based on your findings, with Mr. Doe. Write a treatment note to indicate that this task has been accomplished. Ensure that both you and Mr. Doe sign the modified treatment plan.
Based on your treatment plan, make referrals to at least three (e) community-based organizations to address Mr. Doe’s needs and goals ( i.e. housing, job training, medical, legal, etc.). Write a note about these referrals in his case file. Also, submit the referral forms in your case file.
Send Mr. Doe to a NA Support Group. Locate the support group and document the name of the support group, meeting days and times in his file. Ensure that you counsel Mr. Doe to find a sponsor while attending the meeting. Document the file with the sponsor’s initials.
Mr. Doe is depressed and contemplating suicide because he misses his estranged wife (who is thinking about divorce). Complete a suicide assessment. The suicide assessment reveals that Mr. Doe should be hospitalized, take him to the emergency room and document his case file.
Mr. Doe has been released from the hospital with depression and anxiety medication (research a depression and anxiety medication and document the type of medication (also, the wanted effects and side effects of the 2 medications in his file). He still needs a mental health therapist. Locate a mental health therapist. Make a referral and document his case file. In seven days, consult with the mental health therapist and document the notes, after he signs the release of information form (consenting to the consult with the therapist). Denote what you learned via the consultation with the therapist (Hint: Mr. Doe’s wife is thinking about divorce because she doesn’t understand the process of addiction and treatment. She is tired of her life with him. She wants him to take his sobriety seriously and to get a job). Get a consent from Mr. Doe to bring his wife into a family counseling session. Have a session with both of them. Document the results of the session and refer the wife to an Alanon meeting ( it doesn’t matter that he is struggling with an opiate/benzo addiction, she could still benefit from the support that she would receive by attending these meetings).
Review the treatment plan and modify it to reflect Mr. Doe’s progress or lack of progress on his goals. Ensure that you modify at least one goal to reflect Mr. Doe has a mental health therapist; but, is not attending sessions as often as he should because of his depression. Modify the treatment plan. Note the modification, to the treatment plan, in his case file.
Eighteen months have passed and due to your intensive counseling with him, Mr. Doe he is complying with the program rules, no longer needs methadone maintenance, taking depression and anxiety medication on schedule, making accomplishments on his treatment goals, attending NA meetings, is reuniting with his wife, and is employed. Discharge Mr. Doe from the program.
Although Mr. Doe has discharged from the methadone maintenance program, you believe he could benefit from family counseling and psychoeducation groups from the company’s Intensive Outpatient Program. Develop an Aftercare Plan to include an internal referral for Mr. Doe to attend family counseling and psychoeducation groups . Make final notes in the case file. Close his case because is no longer a client in your department. He is now moving into the intensive outpatient program. He has graduated from attending treatment seven days a week to attending treatment three days a week.
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