Individual Progress AOD note

met with writer in person at Rustin Clinic for an appointment focusing on 
"[textarea memo="quotes" default="" rows="1"]"

Client [checkbox value=" reports new symptoms of| reports worsening symptoms of|denies new or worsening symptoms|reports improved symptoms of|relapse"][textarea memo="other" default="" rows="1"].
 Client discussed current problems, [textarea memo="onset" default="" rows="1"]. Client reports events and/or stressors: [textarea memo="cause" default="" rows="1"]. Writer reviewed relapse/risk warning signs; client identified the following warning signs: [comment memo="warning signs "][checkbox value="isolation|reminders of past|lack of control|conflict with other|not practicing new skills"][textarea memo="other" default="" rows="1"]. However, client also notices that it is improved by: [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"][textarea memo="other" default="" rows="1"]. Warning signs include:[comment memo="Warning signs "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|Experiencing cravings|Fantasizing about using|Bargaining times it would be “okay” to use|Planning physical relapse|Glamorizing drug or alcohol use|Minimizing the consequences of using|Thinking they can control their use|cravings"][textarea memo="other" default="" rows="1"]. Client reports cravings is a [select name="cravings" value="0|1|2|3|4|5|6|7|8|9|10"]; reports motivation for change is a [select name="motivation for change" value="0|1|2|3|4|5|6|7|8|9|10"]; reports safety supports are a [select name="safety supports" value="0|1|2|3|4|5|6|7|8|9|10"]; and reports sleeping on average [select name="sleep" value="0|1|2|3|4|5|6|7|8|9|10"] hours per night. Client [comment memo="Relapse Risks"][checkbox value="reports no  substance use since entering treatment program|reports relapses|reports ongoing substance use with|reports multiple lapses "][textarea memo="other" default="" rows="1"].
Focus: [select value="on topic|needed refocusing"], Mood and Affect:
    Mood- [checkbox value="euthymic|depressed|anxious|angry|irritable|happy|fluctuating"][textarea memo="other" default="" rows="1"]
    Affect- [checkbox value="sad|tearful|labile|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"]
Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity|soft"][textarea memo="other" default="" rows="1"]
Thought process: [select value="logical, linear, age appropriate|circumstantial|"][textarea memo="other" default="" rows="1"]
Associations: [select value="intact|loose|tangential|"][textarea memo="other" default="" rows="1"]
Attention and Concentration: [select value="Adequate attention and concentration based on answers to interview questions|unable to assess due to cognitive impairment|impaired attention and concentration as evidenced by |"][textarea memo="other" default="" rows="1"]
Judgment and Insight:
    Judgment- [select value="fair|good|poor|impulsive"][textarea memo="other" default="" rows="1"]
    Insight- [select value="fair|good|poor"][textarea memo="other" default="" rows="1"]
A) 
Client's progress in achieving treatment goals: [checkbox value="minimal|resistant|making some progress|working on goals, but continues to require assistance with new techniques"][textarea memo="other" default="" rows="1"]
Client is currently demonstrating [select value="symptoms of|little progress|no progress|some progress|"] [checkbox value="emotions|health|sleep disturbance|identifying triggers|practicing new techniques|reframing|impulsivity|mood lability|building supportive relationships|obtainign employment"][textarea memo="other" default="" rows="2"] which is [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="lack of routine|unstable housing|mental health disorder|not practicing newly learned skills|unreliable transportation|interpersonal/family conflict|the stressors of CPS case|maladaptive behaviors|poor psychosocial support systems"][textarea memo="other" default="" rows="1"]. Client would benefit from [checkbox value="continued groups to learn relapse prevention techniques|enhanced psychosocial supports|increasing personal time and self-care|mental health referral"][textarea memo="other" rows="1"]. 
 [checkbox value="Barriers to success include: "][checkbox value="current apprehension to engage in self-help support|current apprehension to engage in structured substance use treatment|current use of substances|limited social supports|dysfunctional interpersonal relationships|poor insight"][textarea memo="barriers" rows="1"]. [checkbox value="Client's strength for success include: "]checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|are well connected with outpatient supports|history of actively engaging in mental-health treatment|high intelligence"][textarea memo="strengths" rows="1"].  [textarea rows="5"]



P) 
Writer will [textarea memo="other" default="" rows="1"]