AMS Dose Response Paper

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.

Mental health: Client reported that he is currently waiting for an appointment for MH services from his OTP. The client reported his intention to continue attending a PTSD support group while in the program. Client denied having any S/I and H/I at this time.

Presenting Problem: Pt is 16 y/o female who is currently at Tuckers Pavilion Acute facility. 8/7/16 Kelly refused to take her medication, and was generally noncompliant to staff directions. She communicated AWOL intent; she also broke a lightbulb to make a number of superficial cuts to her arm, but refused to turn in the glass an dstated that she had flushed it down the toilet. She refused first aid and refused to cooperate with staff directions. She also communicated that she was going to do worse things to herself, Intercept contacted crisis stabilization which transitioned the child to Tuckers Psychiatric at 6am. 8/12/16, Pt was upset to find out she was not getting discharged from Tuckers. Require hydroxyzine 50mg at 1530 medication

Meeting: During intake client was informed and explained the Rules and Regulations of the facility. Case Manager also reviewed orientation packet with client. Client agreed with all rules, signed forms and was issued a copy of all documents signed. Client was informed that she is to comply with the following: Client must meet with assigned Case Manager on a weekly basis. Client must refrain from committing acts which endanger the health or safety of others or that substantially and repeatedly interfere with the orderly operation of the facility, including

The client met with his counselor for his 1x1 session for a case manager with his STOP worker. Client is currently in compliance with his STOP contract. Client has cooperative during his time here at the program is making progress regarding his TX plan. Client has attended outside NA meeting and church meeting after his 60 day blackout. Client is set to get his ID on Friday. Client appears to be willing to do the necessary work. Counselor will meet with the client next week to discuss a plan of action once his leave the program what tools that best fits if he gets frustrated. CADC -1 Yolanda Smith

Patient didn't call or show up for his scheduled individual counseling session today at 7 am; however, he received his dose of methadone at the Clinic around 9 :30 am. This writer called pt.’s phone number on file to reschedule a mandatory individual session. Counselor will be flag pt. in the system to see counselor before dosing tomorrow, 12/15/16 to discuss his recovery progress, what the program expects of him at this stage and how to get the most of out

She informed the writer "someone" applied for housing for her at the Owensboro housing authority. Writer spoke to her about a mental health provider. She informed the writer she sees Dr. Silva and has not been since December/January. Writer asked pt. if she wanted to schedule an appointment with RVBH to see the psychologist. Writer explained the process of attending a therapist before scheduling with the psychologist. RVBH scheduling department did not answer. She wanted to call RVBH back on Thursday.

0745 Telephone contact made to the father of the patient. Two patient verifier used to confirm name and DOB. At the beginning of the conversation FOP did not want to listen to the information that was provider by Lt Wu. FOP states that he has already talk to the Patient Advocacy and IG. Empathic I tried to explain to the FOP that an appt with his PCM was need because their were three no shows for the patient but I could assist him with making an appt. Father starts to screaming stating "that if his son had past scheduled appointment with his provider no on call him for a reminder. " Father becoming verbally abusive using four letter words and swearing. FOP was instructed to call the CAMO to schedule an appt and I hung up the phone due to the

On 1/27/17 I met Mr. Revis at the office of Dr. Geffard PMR. Mr. Revis sister Marie also attended the appointment. The Rainbow Rehab case manager was not at the appointment. I was able to provide Dr. Geffard with a prior medication list. Mr. Revis wants to decrease his medications. Mr. Revis can increase his anxiety regarding a subject fast. Dr. Gefferd is able to redirect Mr. Revis. His focus is being off all of his medications. Dr. Geffard explained that medications will never be completely gone but he will make an effort to decrease and remove what he can. Mr. Revis was very upset about an incident that occurred in his group home. Another resident became angry and hit him in the eye. He doesn’t feel there is anything being done regarding

Intervention/Response: CM received a called from Corporal Williams on Prichard Police Department stating she needs to meet with consumer. CM informed Corporal Williams she will give her a call once she makes it to consumer home. CM traveled to consumer home for the purpose of monitoring and assessing needs. CM was accompanied with CM Shamaiya Williams. CM arrived at consumer home and knocked on the front door. Consumer answered door and met with CM on the front porch. CM contacted Corporal Williams and informed her she was at Consumer home. While waiting for Corporal Williams to arrive CM and consumer discussed consumer medications regimen. Consumer has been taking her morning medications. CM educated consumer on the importance of her taking

Objective A: After 5/2/17, the consumer has missed two appointments with outpatient therapy. The consumer has stated that he wanted to hang out with his friends at the barber shop in lieu of going to his outpatient appointment with the MHSS. The MHSS has discussed the importance of outpatient therapy with the consumer and the consumer acknowledges that he needs outpatient therapy but he refuses to go or makes excuses not to go. Objective B: The consumer and the MHSS reviewed the consumer’s appointments with outpatient therapy and a PCP check up. The consumer was able to review the paper work for the PCP (Dr. Chinnery of Divine Health Group) however he declined help from the MHSS in reviewing the intake packet. The consumer stated that

The patient was placed on hold due to his AWOL status. The patient provide an explanation stating he was not feeling well. This writer discussed with the patient about the importance of daily dosing and th erisk factor of missing a dose will put him at risk for a relapse, at which the patient agreed. The patient then reports he relapsed yesterday and used heroin, 10 bags by IV due to missing his dose. The patient signed a AWOL notice. Furthermore, the patient may consider going inpatient to further help with this relapse so that he can get clean. The patient is aware to notify this writer as soon as possible about his consideration of going inpatient. The patient has a court hearing on 03/07/2016 to address his DUI case.

D-Met with the patient as she was scheduled for counseling. Upon meeting with the patient, she was clearly upset and was seen mumbling under her breath. When asked if everything is alright, her response was, " I am having shitty day." As this writer and the patient walked down the hall to this writer's office, the patient was heard complaining and using profanity. She was strongly advised to discontinue with her comments in the hallway as it was inappropriate. Then the patient continues to vent until she entered into this writer's office about another staff member; however, her comments were heard, which led to the Clinical Director addressing the matter about the patient's comments being disrespectful and inappropriate in this writer's office.

RT had a scheduled medication management appointment with Mary Pestrak at 4:30pm on 6/15/16, but RT called NP Mary and rescheduled. RT stated that she wouldn't be able to come to TSI for her appointment. However, writer met with RT and inquired about RT's well-being and RT stated " I am doing good". RT informed writer that on 6/14/16, she went to her PCP and did blood work and is scheduled to go back to her PCP on 6/21/16 to get the completed physical form hat was provided to RT by writer. RT's medication management appointment is rescheduled for 6/22/16, RT ensured writer that she will be there. Writer informed RT that she is awaiting to hear from Marguerite to get more information on a GED program. RT was appreciative of writer's assistance.

Pt. requested to meet with this writer for a brief session. Pt. informed this writer that she needs to transfer to Connections CSP Inc. because she currently can't afford pay for the AMS of DE TX services. Pt. expressed feeling very concern about her transportation issues and needing to fix her car. Counselor told Pt. that this writer is going to help her with the process but she needs to talk to the AMS Director prior his appointment with Connections program. Counselor encouraged Pt. to obtain information about the Connections program requirements and rules, to pay current AMS balance and to discuss what she learned from this TX. Counselor also assessed her current mental health status which she replied, "I have no suicidal thoughts or mental