Counselling's Case Summary

Counselor met with Pt. for his scheduled individual session for one hour. Counselor and Pt. discussed his progress in tx, any recovery concerns, current dosage of medication effectiveness and future goals. Also, Counselor provided him coping skills to recover from the damage that substances have caused in his life. For the first 20 minutes, Pt. and counselor went over his treatment plan update, completed take home request form and signed his record of service sheet. For the next 40 minutes, Pt. spoke about his treatment and what he wants to get out of it. Pt. indicated that he is striving to never pick up drugs again and is planning to go down in his current 90 mg dosage of methadone. Pt talked about feeling really tired after receiving his daily dose and how he is been taking this dose for 4 months. Pt.

Pt. shared spending a lot of money on line. Counselor asked him whether he consider that an addictive behavior. Counselor told Pt that one addictive behavior can be a trigger for another. Primary Counselor taught Pt. that one way to prevent the reemergence of addictive behavior is to recognize the early warning signs of when he begin to engage in this addictive behaviors. Counselor stated, “That’s when you know to start fighting extra hard to move away from a lapse or a relapse.” Counselor prompted Pt. to identify things he can do to maintain his positive attitude. Pt. agreed that he can help his recovery by helping others and if he would like to provide feedback to other AMS patients during an ams group. Counselor invited pt. to attend and participate in a new AMS Guest Speaker group which he said yes and he wants to be a guest speaker. Pt. also shared that he is going to stay busy by focusing in his tattoo business, painting, learning from staff and calling his two healthy friends when