Patient Interview Journal

The patient asked this writer if this writer cannot talk to her mother and advocate for the patient to the clinic's TEAM about the urgency of getting her bottles. This writer was willing to talk to the patient mother and will try again, to advocate on the patient behalf to get her bottles. However, addressing the mental health portion, the patient stated she has to figure something out about the transportation barrier as no scheduled has been made with CHR due to her barrier. Please note, the patient is no longer seeing Dr. Kuru as the psychiatrist no longer works for CHR. The patient prescriber for her medication is her

D-The patient arrived on time for her session. Reports stable on her dose. This writer discussed about tapering off on her methadone, at which the patient is willing to consider doing, but needs more time. She then says, " I might consider doing it next month, but not right now......I was doing it before, but it stopped....just want to take my time." The patient then discussed about having to go to SSA to obtain the payment for the funeral cost. The patient is upset about the small amount she is about to receive. This writer discussed the grieving process of her loss of her husband and also, her mother in law. The patient appeared to be annoyed with her son for not participating in his grandmother funeral arrangement and also, not showing

D-Met with the patient to address a fax from DCF request of the patient records. The patient immediately said, " Don't send this shit. I cannot stand that worker.....I was in court the other day and I am tired of this and this worker always in my business." The writer explained to the patient that should he continue to refuse to sign an ROI, it may hurt his reunification with his son as the patient detailed to this writer about how DCF got involved in his life ( According to the patient, he was intoxicated when visiting his son and a case was called against him and the child's mother). The patient made it clear to the writer that he has no desires to signed an ROI for DCF and for the clinic to ignore DCF request.

A-Based on this writer's assessment, the patient appeared to be alert and oriented. No evidence of SI/HI.

D-According to the patients she has a surgery on 04/22/2016 for stems in both legs. The patient signed an ROI for Dr. Vandisht for this writer to contact the doctor to obtain a letter stating that the patient can inf fact dose on the day of her surgery. The patient showed this writer with some improvement of her hand with a condition she is unfamiliar that her dermatologist gave her an ointment that cleared her skin. The patient is scheduled to see her dermatologist on 04/29/2016. The patient spent the session discussing an issue with her Fern Manor and its staff members. The patient then signed a ROI for her Pulmonary Doctor. There's still no communication with her older daughter, but the patient still reaches out to her daughter.

Assessment: The patient continues to comply with the clinic's intervention, but continues to test positive for illicit drugs. According to the patient, she bases on her relapses on stupidity. This writer strongly advise the patient to take her recovery serious due to the length of time in treatment and the ongoing positive result as no changes have been made. Please note, the patient appeared to be alert and oriented. No evidence of

(S): Writer met with the consumer on Thursday, 11/9/17 at the consumer home. The consumer had just return from the hospital. The writer asks the consumer why he went to the hospital. The consumer states his legs was hurting him and he needed something for pain. The writer discuss with the consumer about scheduling an appointment with his primary care physician for a complete physical and to let his doctor. The writer did discuss with the consumer about going to the hospital vs scheduling an appointment with his primary care doctor. The writer also inform the consumer that he is schedule to follow up with the doctor on Friday, 11/10/17 at 10:00am. The consumer denied any sleep and appetite problems.

R/s Audra has a mental disability, she suffers from bipolar and anxiety (GAD). R/s Audra is being physically abused by her boyfriend, Peter. R/s Audra is in denial of the danger she is in. R/s the physical abuse could cause internal bleeding due to her factor 5 Leiden disorder. R/s Peter is the payee of Audra’s social security disability check. R/s Peter takes the money to buy crack. R/s Audra lost her car because Peter was spending the money. R/s Peter stopped Audra from going to therapy. R/s Peter attends the methadone clinic and he is giving Audra the methadone. R/s LE was called on Tuesday due to a domestic dispute, but they were unable to do anything because Audra stated she hurt herself. R/s Audra was all bruised up with two black eyes.

Data: 7/13/17 this AOD worker Elba Martinez, and Monica Oviedo, intern, along with LCFS worker Damikka Griffin met with client at 2713 W. Harrison Street for a joint visit. On this day, all children were present; also maternal mother was present. Client was submitted to a toxicology test on this day 7/13/17, and it was NEGATIVE for illicit drugs. Client was provided literature on the checklist about Stay sober over the summer. Client continuous taking the same medicine for DEPRESION AND ANXIATY. Client is attending parenting counseling group, three day a week. Client take IOP counseling twice a week. But currently client is attending once a week, on Mondays, The workers recommended to client in her next appointment don’t

D- The patient reports being stable on her dose. Denies cravings/withdrawals. The patient admits to using last week, heroin-4 bags by IV. The patient denies any trigger use for her relapse, but says, " Girl, I was bored." This writer addressed with the patient that boredom is a trigger and then proceeded to discuss alternatives. This writer then proceeded to discussed with the patient about the opiate postive list for the month of March as the patient is listed for ongoing use for at least 6 months. The patient agreed to participate in a self-help at this clinic. This writer completed a group referral to the Spanish Recovery Group. The patient then reports about her upcoming court date on 05/06/2016 at 9am to address the sentencing. The last

CC met with the member and introduce herself to the member as his new care coordinator. The member report that he would like to schedule another appointment to do his treatment plan because he want to get home and take his medication. CC schedule the member to on Thursday, 2/4/2016 at 10:00am. The member states that the doctor change all of his medication because they were not working for him. The member was unable to sit still and keep getting up and walking around stating he want to go home and try his new medication to see if they will work for him. The member was unable to stay focus and keep talking because the voices keep talking to him and he did not want to hear what the voices had to say. The member states that the voices tell

D-The patient arrived on time for his session. Reports stable on his dose and wants to continue with voluntary taper. The patient located a home in Enfield, CT for $92,000 and is waiting to hear from the bank. The patient discussed the goals for the home renovation. This writer congratulate the patient on locating a home of his liking. Furthermore, the patient report work is busy and nothing really much change. During the course of the session. this writer discussed the patient's next step to his recovery process as the patient wants to do a blind taper. This writer reviewed the patient's recent tx plan and then proceed to discussed his goals. According to the patient, if he was to lose his employment, it will be a major impact whereas

The patient arrived a half hour late to his appointment. He apologized for his no show at his 8am appointment. According to the patient , he made an error to schedule the appointment for 8am rather than 8:30 am due to the bus schedule. This writer informed the patient about calling if he is running late to his appointment moving forward. This writer discussed with the patient recent UDS results. The patient did not deny using illicit drugs; however, he provided an explanation for the cocaine by saying, " I used on Saturday and that is why it shows postive for cocaine .This guy gave me a bad mix by mixing the heroin with cocaine and I wasn't aware of it." Furthermore, the patient used heroin yesterday (2bags and administered by IV) due to the withdrawals of feeling sick, cramps, sweats at night, and having anxiety. this writer completed the dose change request and the patient wants to increase his current dose by 5 mgs.

D-The patient arrived on time to meet with this writer. Reported stability on his current dose, but requested to decrease his dose by 2mgs bi-weekly; stop at 10mgs as he wishes to be stabilized at a lower dose. Then this writer and the patient completed the patient's treatment plan as it is currently due on 02/27/2017. The patient briefly discussed his aftercare plans after he leaves treatment and also, his plans to take ownership of his mother's condo in East Hartford, CT.

D-The patient arrived on time for her session. The patient shared her experience as she attended the cocaine group last week. Based on the patient body language and her demeanor, she enjoyed the group. The patient reports since attending the group, she hasn't used any cocaine for two days on Friday and Saturday. Addressing Sunday and Monday, the patient admits using crack cocaine, by smoking-2 bags because of her anxiety, at which this writer immediately addressed about alternatives. Furthermore, the patient discussed her fear going to detox facility and stated she does not want to go back. The patient believes she needs to attend more groups, at which this writer provided the patient with a list of self-help groups within her community. The