AAM Brought To Sinai Grace: A Case Study

Mr. Goins is a 52 year old male who presented to the ED via LEO following a 4 day binge on alcohol and requesting help with his dependence. Mr. Goins reports he moved to Asheboro recently and found work, however recently lost his job. He reported a history of alcohol use and depression. Dr. Keith requested an assessment on Mr. Goins.At the time of the assessment Mr. Goins denies suicidal ideation, homicidal ideation, and symptoms of psychosis. He reports 5 days ago he became unemployed. Mr. Goins reports his fiance who is his primary support system left town to go to a doctor appointment in their home state of Georgia. He reports binge drinking for the past 4 days attempting to cope with his recent stressor. Mr. Goins reports calling his fiance last night an expressed to her he need help. He states, "I told her I felt at the time no reason to live." Further Mr. Goins stated, "I just had too much in me last night, I had about 14 of them airplane bottles." Mr. Goins denies a history of self harm. He does report a prior hospitalization for depression in Georgia. He also reports a history of attending substance abuse treatment, which was a positive experience for him.

The writer transport the consumer from Common Ground to her home in Brownstown. The consumer did not want to stay at Common Ground because she want to save her marriage. The consumer report that her sister was recently diagnosis with cancer and died about three week ago and she took her sister death really hard. The consumer admit to drinking and doing a lot of yelling at her husband. The consumer states that she was really close to her sister and her death came as a surprise to the family. The consumer states that she lost her mom and dad a few years ago and her sister the only real family she had left. The writer did advise the consumer to follow up with her outpatient provider to see if they offer grief and loss therapy groups. The consumer

Webster want to speak with me. Ms. Webster reported she wanted to know if she could get some Ativan. She states, "If I could get some of that Ativan I would only have to drink two beers a day, I can cut back." She was asked about her earlier alleged statements of suicide. At this time Ms. Webster denies suicidal ideation homicidal ideation, and symptoms of psychosis. She states, "No I'm not suicidal, I just wanted to get into detox." she appears tearful at this time. Ms. Webster reports getting out of jail this past Wednesday and drinking since she has been out of jail. Ms. Webster expressed the only times she feels she can be sober is when she is "locked up". This clinician informed Ms. Webster of the Trosa program and Freedom House who informed TACT of having a bed available for Ms. Webster, however she denied both recommendation. After offering recommendations Ms. Webster asks if she could just receive some Ativan. Nursing staff did inform me Ms. Webster has been expected to be med seeking since her arrvial, however it has been more evident throughout this

D-The patient was placed on HOLD to see this writer to address her no show for counseling on Friday and missed dose as well. According to the patient, she had transportation issue. The patient admitted that she relapsed by using crack cocaine-$20 bags by smoking. Addressing the relapse is due to stressor of her current residency with her "baby-daddy," according to the patient. Alternatives were discussed. The patient asked this writer for assistance again for the contact number to CHR and CVS of which this writer provided. In addition, this writer questioned the patient about her living situation as she reported about it being a stressor in her life. According to the patient, she is no longer residing at her "baby-daddy" resident as she reported

Dr. Gentry requested an assessment for Kaitlin Bradley, an 19 year old female who presented to Randolph Hospital ER reporting suicidal ideation, with a plan, and symptoms of psychosis, and homicidal ideation. She stated " I plan to do some stupid shit". Ms. Bradley reports she has had suicidal ideation daily since the age of 10, She reports that in the past two weeks her suicidal ideation has gotten worse. She reports yesterday she was suicidal and reports if she was going to kill herself she would overdose no whatever pills she can get her hands on. Ms. Bradley reported cocaine and marijuana use, which was confirmed in her drug screening. She reports she came to the hospital so she would not harm herself. Ms. Bradley has a history of suicide

No treatment history was reported. Client reported that she was prescribed medication for ADD, but was terminated on Oct 2015 due to the loss of job and health insurance. Client reported that she has continued to use methamphetamine to cope with her mental health conditions since Jan 2016. No thought of self-harm/suicidal/homicidal ideation was reported. Client indicated her mental health "Poor". "I use meth and heroin. So I don't have to deal with my depression, anxiety, and other issues in my life." "I do go to gamble

Patient presented to the ED via EMS after a attempted suicide by driving his car into a tree. Patient reports braking up with his girlfriend a month ago and experiencing depressive symptoms. He reports that his girlfriend and him had a 7 year relationship, which he shared a with a 6 year old daughter from the relationship. Patient expresses that in the past he has been verbal aggressive towards her and she has recently moved into er mothers home. The patient reports since her leaving he has been having suicidal thought. He reports that he never attempted suicide, however has had a history of depression and a verbally abusive father. The patient express a poor appetite, sleep, and loss in usual pleasure, which is praying for change in his relationship.

Patient is a 46 year old female who presented to the ED via EMS due to overdose on Benadryl. Patient reports financial issues with supporting her daughter going to college. Patient reports depressive symptoms of fatigue,worthlessness, hopelessness, tearfulness,irritable, and anhedonia. At the time of assessment, patient denies feeling suicidal or having a plan. While patient currently denies suicidal ideation and plan, review of the patient's medical documentation does not support that. When confronted about admitting being suicidal and having a plan, the patient presented guarded and later reports she felt like harming herself during overdose due to financial situation.The patient reports she does not want to let any of her daughters down.

MR has unlimited access to group and individual counseling at New Beginnings. It was recommended MR visit a psychiatrist to be assessed for medication. MR does not believe he needs to be on medication, however resources were still given. MR would benefit from medication immensely. He would be able to think clearer and communicate better. It was also recommended MR attend Narcotics Anonymous (NA) meetings daily. After a group session at New Beginnings, all of the clients attended an NA meeting. MR stayed in at the NA meeting for two minutes and then went home. MR does not want to attend NA meetings because he believes he is getting enough help at New Beginnings. It would benefit MR to hear others stories about how drug use affected

Mr. Moore is a 24 year old male who presented to the ED with reports of experiencing depressive symptoms, vague suicidal ideation without a plan, and recent episodes of anxiety. At the time of the assessment Mr. Moore denies current suicidal ideation, homicidal ideation, and symptoms of psychosis. He reported to suicidal ideation would come and go, however never had a plan . Mr. Moore appears calm, cooperative and in good spirits during assessment. He reports a history of anxiety, depression, and emotional trauma by father at the age of 8 years old. Mr. Moore expressed he started noticing increase anxiety when he had to speak in large groups, present in school, driving, and engaging in social actives. He states, "Over the past 16 years my father has been out my live, when I was younger he would hit me if he felt I said anything out of line." Mr. Moore reports recent relationship issues and separation with his fiance. He reports due to him not engaging in many social actives his fiance has left him. He reports for many year going to Randolph Counseling Center for his anxiety. He reports positive results from services. Mr. Moore mention coming to the hospital last Thursday for his anxiety and bring prescribed a 30day supply of Ativan, which he reports has helped him become more stable when engaging in actives,like driving his mother's car. He reports depressive comes and goes depending on the mood he is in. He describes symptoms on occasion as feelings of

The client is an 82 year-old male who has lives in a home for the aged. The client was complaining of sadness, loneliness, hopelessness and states that he wishes to die. He denied suicidal intent or having a plan to hurt himself.

Smith is a 45-year-old-man seeking treatment for anxiety and depression. During initial contact via phone, he repeatedly stated how important privacy was to him and wanted assurances that anything discussed in a session was confidential. In the first physical session, Mr. Smith asked again about confidentiality. As the session continued, he disclosed that the cause of his depression was due to the death of his mother ten months ago. His mother had fallen ill, and he had become the primary caretaker after his father was diagnosed with colon cancer before her death. She suffered from Ischemic heart disease, which required her to use an oxygen tank and she was diagnosed with onset dementia a year ago. Mr. Smith stated that she had been suffering greatly and out of empathy for her gave her an excess dose of sleeping pills during her nightly routine. Upon her death, medical examiners did not question her passing due to her illness and stated: “it would have happened sooner or later.” Presently, Mr. Smith is now suffering from paranoia and has regular night terrors about his mother’s passing. Concurrently, he also feels that he made the right choice due to his mother’s suffering. He continued that his father stated he wishes to be with his wife and hopes to die as peacefully as she did. With that in mind, Mr. Smith feels a sense of responsibility because he also does not want to see his dad suffer but does not want to endure the pain of losing both parents. He is in search

John D. was referred to outpatient therapy for substances abuse counseling by his family member. John was a step down patient from residential treatment and has complete Partial Hospitalization as well. John has past treatment episode and states that this is his fifty-four treatment episode. John reports that he has several periods of abstinence three years and then four at another time. He reports having a high school diploma and Associates Degree. John report no past or present legal problems. He also reports no medical problems past or present. John report he is taking psychotropic medication. John states and has from time to time however does not really like to.

A client admits to alcohol dependency on a consistant and regular basis because the loss of job. The client exhibits hopelessness and depression. The client has explained they experiencing insomnia, and decreased energy to do anything. This explains their poor personal hygiene. As the clinician the safety of the client is of the utmost importance.

The writer met with the consumer at 5627 16th St, Detroit, MI. The consumer report that he is stress because he is homeless has no money and has physical health issues. The consumer did do his intake at New Center early this month but, did not follow up because he did not have a phone or a ride. The writer was able to reschedule an appointment for the consumer for psych eval and treatment plan on 09/01/16 at