Initial Assessment: Current and Historical Problems
Use of Substances Alcohol: (Historic): Preferred drinking vodka daily.
Usage was heavy at about five or more drinks per day Amphetamine: Not Applicable Cocaine: (Historic) Occasionally used a few bumps of cocaine during photoshoots in her modeling career to hide other drug use.
Marijuana: (Historic) Used marijuana occasionally when Percocet was not available until three years ago. Opioids: (Historic) Percocet was the preferred drug. Used the drug daily throughout the day.
Other: Tobacco: (Current). Currently, a heavy smoker and typically smokes about seven cigarettes per day. Medical Issues The client (Kym) was referred to me by the primary care physician, who provided her medical history. Although the client has no record of medical issues, the PCP reports the client showed anxiety symptoms during previous visits, including increased and irregular heart rate, sweating, and fidgeting. This problem could be a symptom of substance use. The reason for referral was to ensure she is treated for anxiety and monitor the ongoing recovery from substance use and mental health issues.
In addition, the client was involved in a car accident a few weeks ago and had minor injuries that did not cause long-term physical or medical problems. Mental Health Issues The client presents with various mental health issues. For instance, she is recovering from substance use disorder, especially alcoholism and opioid and illicit drug use. The client has been to rehab severally and relapsed into using alcohol and drugs. In addition, the client has a co-occurring diagnosis of borderline personality disorder (BPD). For instance, she shows self-image issues and considers herself as the “black sheep” of the family. She also shows unstable interpersonal relationships due to her impulsive behavior, which could have contributed to the use of alcohol and drugs. Although self-image and unstable relationships could be symptoms of substance use, the client continues to show these symptoms even after long periods of sobriety, indicating co-occurring BPD. The client’s casual sex behaviors also indicate mental health issues