Confidentiality Assessment

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Ms. Lewis was referred by Maricopa county correctional health services to receive an evaluation for potential to transfer to the mental health unit. She was serving a 10-year sentence for manufacturing and possession of illegal substances. She had served 1-year of her sentence and reported symptoms of anxiety, obsessive rumination, and sleep disturbances. Notification of Purpose and Limits of Confidentiality Upon arriving for her appointment, the Informed Consent and confidentiality agreement was discussed both verbally and in writing with Ms. Lewis. The purpose of evaluation was reviewed along with mandated reporting laws and danger to self (DTS) and danger to others (DTO). Ms. Lewis signed consent forms for each of the above topics…show more content…
Lewis stated that she believed the meeting was to evaluate for medications, as she was not on any medications at the time of the interview. She reported having high anxiety and rumination throughout her life. She stated that she was constantly worried and could not stop thinking about various scenarios. One scenario she discussed was the possibility of her ex boyfriend finding her upon release. She believed that her anxiety might have stemmed from her excessive rumination. She reported higher anxiety than normal and believed this was related to her incarceration. She also expressed concern over her sleep habits. She endorsed having difficulty falling asleep, as endorsed on her Patient Health Questionnaire-9 (PHQ-9), and often had nightmares involving a monster that was made up of both her father and her ex boyfriend. Ms. Lewis denied any history of suicidal or homicidal attempts. She did however, express feelings of dysphoria, and stated that she sometimes felt as though life was not worth living as endorsed on her PHQ-9. Any history of self-harm was not…show more content…
Lewis reported using methamphetamine recreationally; however, she did not disclose when she had began using or how often she used the drug. Ms. Lewis reported that she drank two to three times a week and generally drank 3 to 4 alcoholic beverages each time. This information was endorsed on her Alcohol Use Disorders Identification Test (AUDIT) scale. Any information regarding cigarettes, caffeine, or other substances was not assessed. Previous substance abuse treatment and unsuccessful attempts to decrease substance use was not assessed Other Relevant History Ms. Lewis had completed 1 year of a 10-year sentence in prison for the distribution of an illegal substance. She reported that 3 years ago she had served 1 year for possession, but denied responsibility for the sentence. She disclosed getting into a fight between 1 and 2 years ago, but did not provide details about the fight. She endorsed a significant history of physical abuse throughout her childhood, and during her romantic relationships. Military, immigration, and custody status was not assessed. Danger to Self/Danger to Other Risk

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