Data Here: Counselor met with client for an introductory session. Client is currently dose at 55mgs of
methadone. Client is currently a phase 0 in program at this time. Client reported he started using heroin
and 15 years ago. Client reported that he is currently using heroin and cocaine daily. Client urinalysis
was positive for Meth, Mtd, heroin, cocaine and fentanyl on 9/24. Client reports that he was 2 inpatient
programs and 3 methadone programs in his lifetime. Client reports that he is diagnose with HBP and is
prescribed medication. Client reports that he is diagnose with Bipolar and Depression disorder and does
take medications. Client reports he attends Redeem on Belair Road for his mental health. Client
reported that his
Plan: Client and counselor discussed the importance of refraining from illicit drugs. Counselor will
continue to educate and support client doing his treatment. Counselor will continue to motivate change
and positive direction which can lead to a successful recovery process.
Assessment Here: Client was cooperative during his group session. Client appeared to be in a pleasant
mood. Client appeared to be receptive for the information given.
Intervention: Counselor and client will explore coping skills to minimize drug cravings by challenging and
changing his thought process. Counselor reminded client of the negative consequences of using illicit
drugs. Counselor will continue to monitor client.
Intervention: Counselor and client explored a coping skill to minimize craving for marijuana.
Plan Here: Counselor and client discussed the importance of not smoking THC. Counselor will continue
to motivate change and positive direction which can lead to a successful recovery process.
Assessment Here: Client presented very positive and happy. Client was very engaged in the conversation
with counselor. Client denied any suicidal or homicidal ideations at this time. Client appeared receptive
to information that was given
Plan Here: Client and counselor discussed the importance of continuing to refrain from illicit drugs.
Counselor will continue to educate and support client doing her treatment. Counselor will continue to
motivate change and positive direction which can lead to a successful recovery process. Counselor will
submit a Take Home application for client first take home
Data Here: Counselor met with client for an introductory session. Client is currently on 80 mgs of
methadone. Client is currently in phase 0 of the program. Client reported her last use of heroin and
cocaine was 6/30/1996. Client reported her length of use was 4 years. Client reported that she got
addicted to pain medications after her back surgery. Client's urinalysis was negative for any illicit drugs
for the last 3 months. Client reports that she was diagnosed with Depression Disorder currently not
prescribed any medication at this time. Client reported that she is diagnosed with Sickle Cell Anemia.
Client reports that she has no income, however she does receive Food Stamp from Social Services. Client
reports that she is currently on unsupervised probation. Client reports that she does have a history of
abuse. Client did not want to get in a conversation about that issue at this time. Client reports that she
live in her own home.
Plan Here: Counselor will discussed the ramification of not providing a urinalysis when requested by
program. Counselor will monitor client while in program. Counselor will continue to educate and
support client doing his treatment. Counselor will continue to motivate change and positive direction
which can lead to a successful recovery process.