Addiction Counseling Progress Note

Nota completa

Client Identification:
adult client attending counseling for concern about recurring alcohol use.

Presenting Problem:
Reports drinking several evenings a week, with some effect on sleep and family communication.

History of Present Illness:
Use increased over recent months during work stress. The client has tried setting limits and had a short period without alcohol, followed by resumed use. No withdrawal symptoms reported.

Past Psychiatric History:
- No prior psychiatric diagnosis or hospitalization reported.
- Denies past self-harm or suicidal thoughts.

Past Medical History:
- No significant medical conditions reported.

Medications:
- No regular medications reported.

Allergies:
- No known allergies reported.

Family History:
- A relative has had problematic alcohol use.

Social History:
- Alcohol use several evenings weekly; denies other substance use.
- Lives with supportive family and is employed. No legal or financial concerns reported.

Mental Status Examination:
- Well-groomed, cooperative; mood mildly anxious, affect appropriate.
- Speech clear, thought process linear, no perceptual disturbance observed.
- Alert and oriented; insight and judgment fair.

Risk Assessment:
- Denies suicidal or homicidal thoughts, intent, or plan.
- No current signs of intoxication or withdrawal; overdose risk not indicated by reported use.

Assessment:
- Alcohol use pattern warrants further assessment; stress is a reported trigger. Client shows interest in change and has family support.

Plan:
- Used motivational interviewing to explore goals and triggers.
- Develop a coping plan and track use before the next session.
- Discussed avoiding driving after drinking and seeking urgent help for severe withdrawal symptoms or safety concerns.
- Follow up at the next counseling visit.

Caso illustrativo con dati del paziente inventati. Non è una cartella clinica reale né una guida clinica. Verifica ogni nota rispetto alla tua visita.

Fatti clinici alla base della nota

Struttura riutilizzabile del modello

Client Identification:
[Client name, age, gender, relevant background information, presenting concern]

Presenting Problem:
[Description of substance use or addictive behavior, duration, frequency, context, and impact on functioning]

History of Present Illness:
[Chronological account of substance use or addictive behavior, triggers, patterns, previous attempts to quit or reduce, periods of abstinence, relapses, and associated symptoms]

Past Psychiatric History:
(hyphenated list)
- [Previous psychiatric diagnoses]
- [Prior mental health treatment or hospitalizations]
- [History of self-harm or suicidal ideation]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]
- [History of hospitalizations or surgeries]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Include psychiatric and non-psychiatric medications]

Allergies:
(hyphenated list)
- [Drug, food, or environmental allergies]
- [No known allergies if applicable]

Family History:
(hyphenated list)
- [Family history of substance use, addiction, or psychiatric disorders]
- [Other relevant family medical history]

Social History:
(hyphenated list)
- [Tobacco use: type, amount, duration, quit date if applicable]
- [Alcohol use: type, amount, frequency]
- [Other substances: type, amount, frequency]
- [Living situation: who lives with client, home environment]
- [Relationship status and supports]
- [Employment/education status]
- [Legal issues or involvement]
- [Financial situation]

Mental Status Examination:
(hyphenated list)
- [Appearance and behavior]
- [Mood and affect]
- [Speech and language]
- [Thought process and content]
- [Perceptual disturbances]
- [Cognition]
- [Insight and judgment]

Risk Assessment:
(hyphenated list)
- [Suicidal ideation or intent]
- [Homicidal ideation or intent]
- [Risk to self or others]
- [Risk of overdose or withdrawal complications]

Assessment:
(hyphenated list)
- [Summary of substance use/addictive behavior]
- [Co-occurring psychiatric or medical conditions]
- [Client strengths and barriers to change]
- [Motivation and readiness for change]

Plan:
(hyphenated list)
- [Immediate safety interventions if needed]
- [Counselling goals and objectives]
- [Therapeutic interventions planned (e.g., CBT, motivational interviewing, relapse prevention)]
- [Referrals to other services (e.g., medical, psychiatric, social supports)]
- [Client education and harm reduction strategies]
- [Follow up plan and frequency of sessions]
- [Return precautions or crisis plan]