D-This writer met with the patient as he arrived late to his counseling session. Reported stable on his current dose and denies the need for a dose increase when offered by this writer. Patient reported of his confidence of producing a negative UDS result for the month of October and the next following months afterwards as he declared, " I haven't been using." This writer asked the patient about the status of the IOP. Please note, the patient attempted to avoid the question by discussing his new employment with XL Center. This writer asked the patient about the hours he works, supposedly in the kitchen and his days off. The patient began to stutter and says, " I work like a 9-5 or longer." This writer questioned the patient as to whether or …show more content…
Please note, the patient had ample of time when this writer was on vacation to conduct the assessment. This writer immediately rendered a Step 3 violation and advised the patient that this counseling session will be placed on TEAM folder as the patient still non-compliant by completing the intake at Wheeler Clinic-IOP. The patient tends to make excuses that aren't legitimate as to why he cannot do the IOP. Please note, the patient was dishonest about attending his group sessions until this writer decided to call Wheeler Clinic of which he confessed about his dishonesty. This writer ensured to address her disappointment of the patient's non-compliance as it is part of his recovery process. This writer addressed the patient history of testing positive for cocaine for more than year, whereas alternatives were discussed with this writer and previous counselors. In addition, this writer removed the patient from the cocaine group over the summer as this writer thought the patient was attending IOP to the need to seek intensive services. The patient was apologetic about his action and did not hesitate to sign the Step 3 violation. He was verbally warned that it can lead to an intent to discharge.
Another deadline was established for the patient to complete the Wheeler Clinic-IOP no later than 10/11, at which the patient again agreed. The patient discuss