Pt. met with Primary Counselor after dosing for her monthly individual session. Counselor started the session respectfully greeting her and praising her for her excellent recovery progress as indicated by her clean UDS. She agreed to sign her Record of Service sheet. For the first 20 minutes Pt. and counselor went over his previous treatment plan and any recovery concern. Counselor and Pt. discussed her recovery progress; possible side effects of her prescribed methadone medication and current emotional status. Counselor inquired about any drug use since her last session, which she replied no. Pt. reported that her current dosage is 80 mg and is unstable because she stays up and unavailable to sleep well at night. For the next 40 minutes, Pt. completed the S.N.A.P exercise and discussed recovery concerns and personal issues. Pt. stated that her strengths are “organization. If I say something to my kids I do it and I finish everything that I start.” Pt. mentioned that her current needs are getting her drive license, passing the driver test and improving my credit score. Pt. identified her abilities as getting along with others, learning …show more content…
presented herself to be positive about her treatment and eager to continue living her new life. Pt. was able to maintain eye contact and had positive body language while speaking with counselor. Pt. seemed glad to speak with primary counselor about her recovery progress and personal concern. Pt. has desire to improve her career and financial status, and increase her knowledge about recovery before voluntary taper/discharge. Pt. appears to display low self-confidence related to her criminal record. Pt. seems to be having no difficulty expressing her feelings and opinion about how the sexual abuse has impacted her life. Pt. seems to recognize that she must encourage herself in order to maintain her current recovery progress and improve her career. Pt. appears to be more open to treatment as indicated by her above