Substance Abuse History

Client is a 29-year-old, white male who began experimenting with alcohol and marijuana at the age of 12. Client states that his experimentation came as a result of peer pressure from a group of older friends. Client also states that his initial experience with these substances were solely in effort to “impress” this group of older acquaintances. Over the course of the next several years, up to the age of 16, the client drank alcohol (typically beer or vodka) and smoked marijuana cigarettes almost every day after school in his neighbor’s back yard.

Client states that his parents and his neighbor’s parents were working during this time and remained unaware of the behavior. After the age of 16, Client began to experiment with cocaine and crack at parties. At the age of 18, upon graduation from high school, Client indicates the use of alcohol on a daily basis and a “need” for alcohol to complete daily tasks. Client also indicates his continued use of “any available drug”. Client states that he has used alcohol on a daily basis for 11 years and has smoked marijuana, snorted cocaine, and experimented with additional drugs on a weekly basis (3 to 4 times per week) .

Client indicates his desire to impress older friends at a young age has become a way of life and that the majority of his youth was a “blur”. PSYCHOLOGICAL FUNCTIONING Client appears to be healthy and normally functioning for his age. Client’s physical appearance is on par for his age of 29. Client’s weight is within the normal range for his height. Client has no obvious physical deformities. Client is well-dressed and clean. Client off puts no evident body odor. Client’s hair is combed and ‘styled’. Client’s posture is relaxed.

Client initially sits down with his back against the chair and shortly changes his positioning to a posture wherein his elbows are propped on his knees and the weight of his leaning torso is rested on his elbows. Client exhibits no facial tics or nervous physicality. He appears to be physically comfortable and shows no signs of pain or discomfort. Client’s facial expression seems oftentimes disinterested but does exhibit signs of regular engagement. Client does smile and laugh lightly on occasion during recounts of his past. Client’s speaking tone and rate is moderate.

He speaks with a tone that indicates confidence in communicable abilities. Client seems to be friendly and comfortable with his current surroundings and is, by all accounts, in a good mood. Client is not hostile or aggressive. Client exhibits no verbal or physical hostility. Client seems uninhibited and exhibits a willingness to cooperate. Client does not appear to have obsessive tendencies throughout the course of the interview nor has he made any inappropriate responses. Client seems fully aware of his present condition and does not verbally blame his current situation on any one event or individual.

Client appears to take full responsibility for his current state. Client does not appear to be delusional about his circumstances and exhibits no extraneous thought during the interview. Client states that his regular use of alcohol makes him feel calm and lethargic. He indicates that daily alcohol use keeps stress at bay. He indicates a lack of concern about his job or responsibilities with alcohol in his system. He also states that, to gain motivation to accomplish physical tasks, he uses cocaine. He indicates that cocaine use gives him an obsessive drive to “get things done”.

One such example is the Client’s recent cocaine use when helping a friend move. Client indicates a drive to remain in social situations. He feels uncomfortable when he’s alone. Client indicates that, although he lives alone, he regularly allows friends to “crash” at his home. He also indicates a desire to bring members of the opposite sex to his apartment more for companionship than for sexual gratification. He states that his drug and alcohol use feels like less of an impairment when he is engaged in social activity. Client is well aware of place, time, and person and appears to be of average intelligence.

Client has an appropriate present memory and an appropriate concentration level that is in within normal range. Client does exhibit some inability to recall vivid details of past experience, however, his past recollection is within normal limits. Client does have a slightly diminished level of self-worth and seems to be a bit hard on himself. He does express feelings of guilt over his past and present behavior and circumstances. However, client does exhibit a confidence in his abilities to succeed in life overall. EDUCATIONAL/VOCATIONAL/FINANCIAL

Client did graduate high school and was among the top 200 in his class of 500. Despite his substance abuse, client was active in high school athletics and had an after school job at a pizza parlor starting at the age of 16. Upon graduation from high school, client enrolled in community college but dropped out in his first semester. He secured a job as a waiter at a popular local restaurant and earns enough gratuity to pay rent, utilities, and cell phone bills. Client has a very small amount of credit card debt that is in good standing and has otherwise maintained his financial responsibility.

Client’s work experience is entirely service oriented and he has an extended knowledge of the hospitality and restaurant/food service industry. Client has been able to maintain his job/career in the restaurant business despite his drug and alcohol use. He indicates that the restaurant business lends itself nicely to an addictive lifestyle. LEGAL HISTORY Client has no legal history and has never been arrested or convicted of any crimes. Client has no pending cases. SOCIAL HISTORY Client is the oldest of two children in a two parent household.

Client indicates that his parents remain married and have a seemingly ideal relationship. Client also indicates that his parents’ devotion to career meant that he and his sister were often left on their own. Client indicates an above average childhood in terms of monetary worth. He states that he always had more than he needed and was never physically, emotionally, or sexually abused. Client states that his parents only had wine or champagne on special occasions and that neither became aware of his substance abuse until his late teens.

Client has been involved in a number of casual heterosexual relationships and three serious relationships. Client states that he’s very eager to find his “soul mate” and is a bit jaded when it comes to the opposite sex. He has experienced infidelity (on the part of his partner) in two of his three relationships. Client states that his last serious relationship dissolved as a result of his substance abuse. Client indicates a desire to resolve matters with his last partner. PHYSICAL HISTORY Client appears to be healthy and normally functioning for his age.

Client’s physical appearance is on par for his age of 29. Client’s weight is within the normal range for his height. Client has no obvious physical deformities. Client states he has always been of average build and has never experienced weight problems. He also indicates that he enjoys exercise but has not, as of late, performed physical activity without aid of cocaine. Client does not take any prescription medication nor does he suffer from any medical problems. Client has no known physical impairments at this time. Client indicates no sleep problems and experiences no appetite irregularities.

Client does indicate daily alcohol use and weekly drug use. Client does not smoke tobacco cigarettes and indicates no desire to do so per his regular marijuana use. TREATMENT HISTORY ASSESSMENT DSM IV Axis I Diagnosis 304. 80 Polysubstance Dependence: Predominantly alcohol, marijuana, cocaine. Presenting Problems Client states that he is well aware of his need for help to stop his substance abuse. He exhibits sincerity in his desire to stop using. Client indicates a desire to progress in life and to someday begin a family.

Client states that his present addictions will prevent him from living the life he longs for and he is ready to move forward in life. He also indicates a concern that his substance abuse will shorten his life if he does not get it under control soon. Client indicates a desire to open his own restaurant and a desire to complete education necessary to do so. He indicates a longing to progress his reputation in community involvement and even indicates a desire to become active in church. TREATMENT PLAN DISCHARGE SUMMARY Client is a 29-year-old, white male whose diagnosis is polysubstance dependent (alcohol, marijuana, and cocaine).

Client has exhibited psychological function that is within normal limits and has no displayed hostile or aggressive behavior. Client has a level of intelligence that is within the average range. He has the ability to read and write. Client has adequate educational/vocational/financial capabilities and exhibits excellent potential for success in education and career. Client has no legal history. Client has no history of physical, emotional, or sexual abuse. Client has no known current medical conditions. Client has never had prior substance abuse treatment. (…. ).

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