Intake Summary Report

Intake Summary Report Identification: The client is a Caucasian, 29-year-old male. He is currently in a relationship with a child who is 10 years old. He currently works for Rivers and has been there for 5 years. He reported he makes roughly 15,000 per year. His girlfriend works for Great Planes. He was referred by Washington County Court Judge for an evaluation after he got a DUI with a BAC of 0.12%. This is his second DUI the first time was a BAC of 0.18%. Presenting Problem: The client reported that he was court appointed to attend sessions but did mention that he believes he has a drinking problem. He recently lost someone close to him and said that drinking helps him get through his grieving process. He stated that there are complications in his relationship due to his drinking and his girlfriend said if he does not stop drinking, she will have to move out. This has caused a lot of stress and anxiety on the client. The client stated that he drinks 3-4 times a week after he gets off work. He said that he drinks anywhere between 10-15 beers when he does drink. He sometimes will get sick and shaky in the morning after a night of drinking which can throw him off for the day. The client is currently working for Rivers and before that he has history of cooking for a few different restaurants. He stated that he plans to find a second job to bring more income in. Drug Use History: The client reported that he currently drinks alcohol, smokes weed, and smokes cigarettes. He stated that he began drinking when he was 14 years old and the reasoning for starting was, he liked the feeling he got after drinking. He feels as if he has not always had a drinking problem it recently picked up after he lost his brother to suicide. He used to just have a few drinks on the weekends and now the drinking occurs more frequently. The client reported that he drinks 3-4 times a week and usually ends up drinking 10-15 beers. He smokes weed every day. He informed me that during his withdrawal periods he gets very shacky and feels sick the morning after he drinks. He said that he no longer drinks for fun he drinks to black out so that he does not have to feel pain due to his loss. He stated that he feels like drinking is taking over his life and he would like to get help. He is also very scared that he may ruin his relationship if he does not stop drinking. He just got picked up for his second DUI and the judge mandated that he get an evaluation done. Mental Status: During the intake process the client shook his leg a lot and struggled with making eye contact. He also was biting his nails during the intake. He stated that he is very depressed and that he just started feeling that once he lost his brother to suicide. He stated that he is not suicidal but feels like the alcohol could kill him if he does not stop drinking. The client stated that he gets bad anxiety that makes him overthink about things going on in his life. He stated that he feels like all he does is work and it can stress him out at times. He sounds like he enjoys his job and is an extremely hard worker. He graduated high school with straight A’s, so I feel like he is above average of intelligence. He said that he works and comes home. He has a strong relationship with his daughter and said that he is available to hang out with friends and family. I would say that he has plenty of social connections with his friends and family. Predisposing Factors: The client is the middle child. He has an older brother and 3 younger sisters. He has a remarkably close relationship with his siblings. He stated that he just recently lost his brother to suicide and that has really taken a toll on his life. He is the only sibling that drinks in his family, but both his parents are alcoholics. The client stated that he is close with his mom, but his dad is not really in his life. Both his parents are recovering alcoholics. The client reported that he has never been abused but feels neglected from his father because his father does not try and have a relationship with him. He stated that him and his mom are super close and always have been. The client informed me that his parents do not have a relationship at all. They have not talked for many years. They are divorced and have been most of his life. He said he cannot remember how they were together because he was so young. The most traumatic thing to happen to him was losing his brother to suicide. When I asked about his cultural background, he did not want to talk about it. He said that neither parent have really talked about their cultures. He did state that his mom had them go to church every week and he got confirmed from the church in his hometown. Lifestyle: The client described himself as very personable and outgoing. During the intake he seemed very friendly and enjoyed talking. He said his typical day is to wake up around 7am and get his daughter ready for school. He then said that during the day he does housework and then heads to work around 2pm. He stated that his girlfriend picks up his daughter from school since he is working. He normally does not get off till around 10pm or 11pm and he then goes home and most nights he drinks. He said he enjoys watching Netflix and drinking beers before he heads to bed. He stated that his hobbies are skateboarding but does not make enough time to do what he enjoys because of work. He stated that he goes to sleep extremely late and wakes up early. The client stated that he eats breakfast and lunch before he heads into work and then he normally eats dinner while he is working. Test Results: The client was administered two substance abuse evaluations. He completed the Mast Alcohol Assessment (MAST) and the Substance Abuse Subtle Screening Inventory (SASSI). Test: MAST SASSI Score: 17 Any rule answered yes Interpretation: Hazardous Drinking/Alcohol Dependence High Probability of Substance Abuse On the SASSI evaluation the client scored a 29 in the Face Valid Alcohol and a 36 in the Face Value of other drugs. With the results of this evaluation, I have concluded that the client has a high probability of substance abuse. The client mentioned that his drinking is out of control, and he no longer can stop on his own. On his MAST test he scored a 17 which concludes that he is a hazardous drinker. Dynamic Formulation: As can be seen by the scores of the evaluations I would say that the client in fact does have a substance abuse problem. His scores were extremely high which tells me that he does in fact struggle with alcohol/weed. The client has stated that he no longer has control over his drinking, and he thinks that it is becoming a problem. He has stated that he would like to investigate further options as far as treatment centers. The alcohol is now something he does regularly and is close to losing his relationship. The client has described his life as depressing. He said that drinking is constantly on his mind and if he is scared that he will not have his daughter in his life if he continues to drink. He has mentioned multiple times how sad it makes him that he decided to get in a car drunk but is happy he got caught so that he did not end up killing someone or himself. Prognosis: I feel that the client would benefit from getting into an outpatient treatment or even a treatment center. Treatment Recommendations: The counselor's treatment recommendations would be that the client turns himself into a treatment facility and attends Alcoholics Anonymous meetings. She recommends a 30-day program of inpatient treatment.