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Clients Name: Justin Time DOB: 01/01/1993 Date Seen: 11/11/2012 Referred by: A friend of the clients Clinician:

Stephanie Suggs Presenting Problem: The client reports that he is seeking help after being referred by a friend who used our services in the past. The friend was concerned that the clients constant and overuse of alcohol was causing the bulk of the problems in his life. The client is homeless, having been kicked out of his home due to his excessive drinking. The client is currently living with his best friend and his family. He states that it is a better environment. He states that he is sharing a room with his best friend and has his own bed. The client is seeking help with his drinking problem and his living accommodations. Family History: The client is 19 years old. The client is unmarried and has no children. His mother is a 47 year old nurse at a hospital. His father is a 50 year old customer service representative at a store. The mother and father divorced when the client was 11 years old, after 5 years of marriage. The father isnt living in the home where the client and the mother reside. The father lives 30 miles from the clients residence. The mother has two other children, both girls, ages 5 and 11. Both of the sisters have the same father, but is not the clients father. The client states that the father of the two sisters lives in the home. The father of the two sisters is a 49 year old that doesnt work or support the household in a financial capacity. The client states that the boyfriend sits at home all day watching television and coming up with get rich quick schemes that takes money out of the families pocket. The clients father is the only child with one living parent living. The living parent is the grandmother who is 75 years old and is living in a nursing home due to declining health and Alzheimers disease. The parents of the mother are both deceased. The mother has two sisters that live in another state. Both sisters are younger, ages 42 and 44. Neither one of the sisters have children and the youngest sister is recently married. School History: The client has a high school diploma. He is considering attending a technical school to become a mechanic. Work History: The client has continuously worked part time at KFC since he was 16 years old. His part time income is not enough to support himself independently. Medical History: The client states that hes been experiencing frequent headaches starting a month ago. He states that he drinks at least 4 times a day; usually hard liquor such as rum or vodka and at least 4 beers a day. The client also stated that during his last physical, his physician stated he is pre-diabetic.

Assessment: The client is a 19 year old male who came into the clinic seeking help for his excessive drinking problem and his living situation. He was concerned about the living arrangements at the house he was living in with his mother, two sisters, and the mothers boyfriend. It is possible the client is experiencing a high level anxiety due to the stress of is at home living situation with the mothers boyfriend, not having a high paying job, and drinking. The client seems to be happier in the home of his best friend and his parents. DSM IV Diagnosis: Axis I: Adjustment Disorder with Anxiety. Axis II: None Axis III: Headaches, Pre-diabetic Axis IV: Homeless, excessive drinking, low paying job Axis V: GAF 75 Treatment Plan: 1. Start AA meetings starting within seven days. Times and locations will be provided to the client. 2. Make an appointment with a physician at a hospital, doctors office, or clinic to address the issue of the headaches, follow up on blood work to assess the pre-diabetes, and to have a full check up. 3. An appointment for family counseling for the mother, client, and possibly the rest of the family. 4. Find a more permanent residency for the client.