Case study – attachments are provided

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Case study – attachments are provided

Case study – attachments are provided
Help Me! Full Assessment of a Case Study Client Name: Roberta Assessment Date: 05/07/2023 Substance Use History Drug First Use: Yes or No Pattern of use over time? Frequency of use in past month? Date/Amount of most recent use? Diagnostic Criteria Checklist Criteria Yes No Criteria Yes No Was the substance taken in larger amounts or over a longer period of time than intended? Were important social, occupational, or recreational activities given up or reduced because of substance use? Is there a persistent desire or unsuccessful efforts to cut down or control substance us? Has the substance been used recurrently in physically hazardous situations? Was a great deal of time spent in activities necessary to obtain or use the substance, or recover from the substance? Has use continued despite knowing of having a persistent or recurrent physical or psychological problem that is caused or exacerbated by substance use? Have they continued to use the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the substance use? Has recurrent use of the substance resulted in a failure to fulfill major role obligations at work, school, or home? Is tolerance present? Is withdrawal present? Is there a craving or strong desire or urge to use the substance? DSM-5-TR Diagnosis: DSM-5-TR Diagnostic Code: Assessment Analysis Basis of Diagnosis (A one paragraph explanation of why you chose this diagnosis.) Applicable Theory (Apply a model of addiction to the client’s case. Provide a paragraph description of a theoretical framework that would explain this client’s substance use history, followed by a minimum of one fully developed paragraph explaining how the theory applies to this client.) Sociocultural Factors (In two paragraphs, describe the sociocultural factors influencing or effecting the client’s substance use and/or recovery.) Motivation for Change and Relapse Prevention (In two paragraphs, describe the client’s motivation for change and initial thoughts on relapse prevention.) Ethical Considerations (Based on NAADAC code of ethics.) Confidentiality (Describe the requirements of confidentiality, what the ethical exceptions are to it, and what it means for this client.) Appropriate Relationships (Describe the ethical limitations of the relationship between client and therapist, consider dual relationships, sexual relationships, and past relationships.) 3

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