fictional case study essay

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The purpose of this interview was to assess the patient’s need for habit treatment by reviewing person’s present and former usage history, emotional and behavioral stableness, and potential for relapse, environment, pertinent medical conditions, and readiness or desire for treatment. An interview and medical records collected this info.

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Name: Lewis Jacobson Time: May six, 2005

Age group: 25 years outdated Gender: Men

Ethic history: Caucasian Birth date: February 3, 1980

Residence: 161 And. Ray St . Minneapolis, MN Referral: The courtroom ordered

Your customer is being assessed today as a result of a confidence of driving drunk.

The lording it over judge ordered the client to obtain professional help with addiction complications. This examination will identify level of advised treatment, if any treatment is needed.


Client’s consumption history started out when consumer was approximately 15 years old (usage is around 10 years). Client claims the he could be currently a ‘heavy’ consumer who frequently drinks till drunk. Consumer states that he uses alcohol 5-7 days weekly, with intake ranging from 6-24 beers every occasion.

Client even offers a history of heavy medicine use. Customer states that alcohol is a present drug of choice, nevertheless admits to occasional marijuana and cocaine use. Pot usage is approximately once a month, crack use is approximately 3-4 times a year, and amounts utilized are unknown.

Client can be described as 2 load up a day cigarette smoker. Due to client’s liquor use, consumer was recently convicted of driving under the influence of alcohol and ordered to seek help. Consumer was placed in a junior detention middle in high school for theft and in the end was expelled from frequent school, finishing his education at a continuation secondary school. Client reports significant social and relationship difficulties. Consumer presents without history of alcohol, marijuana, or cocaine drawback symptoms and does not appear to be suffering from symptoms currently. Client claims that he could be not presently experiencing smoking withdrawal, on the other hand there is possibility of nicotine disengagement

Risk level: Due to not enough significant and harmful drawback symptoms, risk level is 0.


Customer states this individual has a great impotence (medically untreated). Consumer does not have any regarded medical conditions that could prevent restoration. Client is without known allergy symptoms, no at present prescribed prescription drugs, and smokes tobacco daily.

Risk level: Due to deficiency of interfering health concerns, risk level is zero.


Consumer states that there is no known history of earlier diagnosis or treatment for psychological concerns, nor any kind of current or perhaps previous use of psychiatric medicines. Presently, there have been no regarded psychological testing or emotional consultations. Customer complains of depression, panic, thoughts of suicide, low self-esteem/ self-concept, and anger. Client states that he attempted committing suicide a couple of years in the past. Client declares history of panic is source of impotence. Consumer presents to get anxious, peaceful, well groomed, and orientated. Client’s speech is normal and thought procedures appear to be existing.

Risk level: Due to great suicide efforts and thoughts of committing suicide, risk level is installment payments on your


Client declares he is motivated to change also to stop drinking. Client is still unsure in the event he is dependent on alcohol and feel he’s addicted to weed or crack. Client admits to cigarette smoking addiction; yet , at this time client is not really motivated to cease smoking usage. Consumer is accessible to individual remedy, outpatient alcoholic beverages treatment, and self-help groupings. Client seems that these options will assist in his restoration. Client claims he is willing to follow the tips of current assessment.

Risk level: Client is determined to change drinking and mental issues, although does not view marijuana and cocaine consumption as a concern. Client does not desire to modify nicotine usage. Risk level is a one particular, as consumer shows a willingness to change.


Client does not have know good previous treatment options. Client wishes treatment as a result of unhappiness with current life style. Client states that his longest disuse from liquor is 4 days, cigarette smoking an hour, and marijuana and cocaine 1-2 years during the last 5 years. Client acknowledges several triggers for having episodes (social anxiety, loneliness, fear, thoughts of inadequacy, and guilt). Client can be not going through any desires for chemical substances at this time (currently using nicotine). Client says he provides current complications with family problems and anger, self-esteem, and anxiety that are unresolved. At this point, potential for urge is average to extreme. Client a restricted support network with no relapse elimination plan.

Risk level: Because of short duration of sobriety, not enough support network and relapse reduction plan, and current psychological issues, risk level is 3.


Consumer lives exclusively. Client works full time in constructions and studies psychology part time in a local college. Client declares he will not have any kind of social close friends and he’s a ‘loner’. Client offers poor relatives relationships. Customer is single and includes a history of risky relationships. Consumer hasno prior involvement with self-help groupings or strong support systems.

Risk level: Due to deficiency of a supporting social network, a lot of criminal activity, and deficiency of counseling services risk level is definitely 2 .


Client identifies his chemical substance usage as being a problem and it is motivated to alter. Client can be open to remedy, and willing to work on previous and present issues. Consumer is aware of triggers. Based on client’s age, work history, and level of inspiration, it is very probable that client will be successful in recovery. Development of a social network, adherence to legal outcome of driving drunk of alcohol, and taken care of healthy actions are areas that should be addressed and a relapse elimination plan ought to be designed to support and motivate these areas.

It is recommended that the consumer be confessed to an outpatient treatment program. Person therapy and attendance into a self-help group are also recommended. Client needs to create a support network. Continual work on self- image, goal setting, and marriage issues is. A comprehensive hunt for suicidal fantasies is firmly recommended. A psychological evaluation is also advised to address virtually any possible feeling or anxiety disorders, with constant monitoring and adjustment as needed. Coping skills teaching and tension activities are recommended. Preparations have been created for client to start outpatient treatment on Mon, May of sixteen, 2005.


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