REASON FOR ASSESSMENT
Assessment completed to document the extent of substance use and criminal history to include completed assessments of alcohol consumption, substance use and trauma history, to be used to determine Donna “Patty” Cunningham’s current treatment needs. Also, an assessment of strengths and needs, current living situation, relationship with her significant other, current substance use, social support, financial needs, recovery goals and basic needs. Patty has never received any past counseling or drug treatment.
SOURCES OF INFORMATION
Information provided in this assessment was obtained through self-report, family input and family history.
PSYCHOSOCIAL HISTORY
During the intake assessment, Ms. Cunningham will be assessed
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Ms. Cunningham, will be further referred to as Patty. Her mood is unpleasant and aggressively interacts throughout the assessment process. No current or past suicidal ideations noted. Patty has historical issues with cutting since the age of nine; however, any recent cutting behaviors are denied. No detoxification or rehabilitation treatment for substance use noted with the exception of historical incarceration.
Patty was raised in a single family home with her mother and siblings. Patty is the fifth child of eight children. All of Patty’s siblings have criminal history and substance abuse issues with the exception of two older brothers. Patty’s two older brothers escaped poverty benefited from outside intervention. They acknowledge a social worker and a teacher for assisting them with their mission. Several maternal family members also had drug and alcohol issues such as her uncles and grandfather. Patty’s father is
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Patty should answer to and resolve all pending legal issues and adhere to the decisions of the courts responsibly. A psychological evaluation needs to be conducted to determine Patty’s cognitive functioning relating to intellect, vulnerability and personality. The evaluation should also assess life events that contributed to substance use.
Treatment recommendations will all be dependent upon the resolution of current legal issues.
Patty has never undergone any treatment for substance dependence; therefore, intensive treatment for identified addiction to opiates, alcohol and other illicit substances should be a primary goal. Beneficial treatment for Patty would include comprehensive individual and group therapy that places emphasis on the harmful effects of substance abuse. A positive community support system or sponsor should also be identified. Due to Patty’s limited education, various media should be incorporated into treatment, such as, videos, handout and group exercises. Consistent and continual monitoring of progress should be assessed and modified as needed to solidify or reinforce goals as they