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Agency Project. By: Kami Perez. Patient 100780. Name: Sarah Noone White female 31 y/o Single mother of two Occupation- waitress Substance Abuse- Percocet, Opana, Marijuana Length of Abuse- 8years. Screening. Patient 100780- Sarah Noone
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Agency Project • By: Kami Perez
Patient 100780 • Name: Sarah Noone • White female • 31 y/o • Single mother of two • Occupation- waitress • Substance Abuse- Percocet, Opana, Marijuana • Length of Abuse- 8years
Screening • Patient 100780- Sarah Noone • The screening process determines the patient’s appropriateness and eligibility for admission. • Evaluate psychological, social and physiological signs and symptoms of alcohol and other drug abuse. • Identify any co-existing conditions.
Intake • Complete documents for admission. • Complete documents to support eligibility and appropriateness.
Orientation • Describe program goals and objectives. • Describe program rules, client obligations, and client rights. • Explain how the program operates, what the patient needs to know to access and use services and hours of operation, emergency contact numbers, staff availability and activity schedules.
Assessment • Gather history • Identify assessment tools. • Develop a diagnostic evaluation of the patient’s substance abuse and any coexisting conditions based on the results of all assessments; include strengths, weaknesses, and identified problems and needs.
Treatment Planning • Explain assessment results to patient. • Identify and rank problems based on the patient’s needs. • Give examples of goals, short term and long term. • Identify treatment methods/resources to be used.
Counseling • Select the counseling theory that applies for the patient. • Individualize counseling in accordance with cultural, gender, and lifestyle differences. • Elicit solutions and decisions from the client. • Implement the treatment plan.
Case Management • Coordinate services. • Explain the rationale of the case management to the patient.
Patient Education • Presentation of relevant AODA information. • Presentation of available AODA services and resources.
Referral • Identify needs/problems that the counselor or program cannot service. • Explain to the patient why the referral is being made. • Match needs to resources. • Assist the client in accessing the services.
Reports and Record Keeping • Chart ongoing information pertaining to the patient. • The utilization of information from written charts for patient care.
Consultation • Recognize areas of care need that are beyond the counselor’s base of knowledge and/or skill. • Requires consultation with resources to ensure effective treatment services.