P-Next Placement Summary
D-The patient was placed on HOLD to address her no show for last week. This writer asked the patient if she was okay with tomorrow 's appointment based on her appointment letter. The patient to do the session today since she 's already present and waited for this counselor. This writer agreed to conduct the session. Reports stable on her dose and deny the need for a dose decrease as she denies any cravings/withdrawals.
DCF case status:
According to the patient, her grandson 's mother has unsupervised visitation with her son as long as it is not overnight visitation. Furthermore, her grandson mother has to follow through with DCF recommendation such as having stable housing, no THC, and parenting class.
Patient 's health:
The patient admits to not following through with seeing her PCP about the thyroid issue. This writer strongly advised the patient to scheduled an appointment before her next scheduled session and update this writer, at which the patient agreed to do.
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UDS result:
The patient recent was negative from all illicit drugs.
Other:
The patient is not interested in pursuing the mental health services at the moment as she expressed about not being ready for it at this time.
A-Based on this writer 's assessment, the patient appeared to be alert and oriented. No evidence of SI/HI.
P-Next appointment is scheduled on 07/1/2016 at 11am. Patient is aware about being placed on HOLD for the counseling
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