G: Met with client for weekly case management session and to address housing goals. I: CM met with client to inquire about updates related to housing goals. CM used open ended questions as an MI technique in order to get the client to envision his life without drugs.CM specifically address the issue of sobriety as it pertains to the client’s status for orthopedic surgery. CM continued to assess for PTSD symptoms, substance abuse, and medication compliance. R: Client presented well-groomed and with good hygiene. He was seen casually dressed and was open for discussion. Client 's affect was appropriate and congruent to his thought content, and his mood appeared happy. Client reported attending the VA joint clinic in WLA on 3/2, in where he …show more content…
The client reported having mixed feelings regarding sobriety and blamed his environment (Skid Row) for his continued drug use. Client reported being reluctant to stop using heroin in order to be consider a good candidate for surgery by the WLA, VA. He reported that he will only consider sobriety for surgery, if Medicaid coverage fails to provide surgery for his knee. The client was able to describe the barriers that enable him to continue his dependency on opiates such as his refusal to interact with his family even after they ‘ve attended to make contact with him. Client reported finding comfort in “being what everyone expects him with his addiction”. Client admitted that he fears sobriety and reaching out to his family because he feels like he would let them down and “wont be able to live up to the expectations”. Mental health: Client denied having any PTSD symptoms at this time. Client denied S/I, H/I. Client continued to reject consult for MH services. Financial: Client agreed to contribute $150 into the program’s savings plan by 3/29. Client’s main source of income is his VA service connection check in where he receives $834 a month for hearing loss and tinnitus. The client ‘s VA disability rating is at 50%. P: CM and client will continue to meet on a weekly basis to explore his barriers related to housing and substance