Presenting concerns and background information
Document client identifying information, reason for seeking counselling, medical and mental health history, living situation, support network, employment status, trauma history, and specific substance use concerns.
Substance use history and pattern of use
Detail substances used, routes of administration, frequency, quantity, duration of use, context of use, most recent use, withdrawal symptoms, previous treatment attempts, and current treatments.
Impact of substance use
Document effects on physical health, mental health, social relationships, employment/education, legal issues, and financial situation.
Withdrawal and dependence indicators
Note tolerance levels, withdrawal symptoms, failed attempts to control use, and time spent obtaining, using, or recovering from substances.
Motivational interviewing and readiness for change
Identify client’s stage of change, ambivalence about reducing use, personal goals, previous change attempts, and barriers encountered.
Risk assessment
Document suicidal ideation, self-harm risk, overdose risk, harm reduction strategies, domestic violence or safety concerns, protective factors, and existing safety plans.
Strengths
Identify coping strategies, support systems, meaningful activities, and past periods of successful substance reduction or abstinence.
Assessment and testing
Record results of psychometric testing, questionnaires, or surveys, and plans for further assessment.
Treatment plan and next steps
Document agreed treatment goals, planned interventions, referral needs, follow-up session details, and client homework or activities.
Presenting concerns and background information
- James Wilson is a 42-year-old male who self-referred for alcohol counselling following GP concerns during a recent health check.
- He reported living alone following separation from his wife six months ago and has two teenage children who stay with him every second weekend.
- James disclosed a history of depression diagnosed three years ago (currently managed with sertraline) and works full-time in construction management.
- He identified his primary concern as escalating alcohol consumption, stating he “can’t handle it on my own anymore.”
Substance use history and pattern of use
- James reported consuming 8-10 standard drinks daily (beer and whiskey), increasing to 12-15 standard drinks on weekends, typically drinking alone at home after work.
- He stated this pattern developed over approximately 18 months with significant escalation following his separation.
- Indicated his last drink was yesterday evening with mild tremors experienced this morning. He disclosed two unsuccessful attempts to reduce drinking in the past three months.
Impact of substance use
- Reported physical health impacts including disturbed sleep, weight gain, and elevated liver enzymes noted by his GP.
- Described experiencing worsening depression symptoms, concentration difficulties, and withdrawal from social relationships.
- He reported strained relationships with his children who have commented on his drinking, declining work performance, and spending approximately $200-250 weekly on alcohol.
Withdrawal and dependence indicators
- James reported increased tolerance to alcohol compared to a year ago and experiencing tremors, sweating, anxiety, and sleep disturbance beginning 8-12 hours after his last drink.
- He described multiple failed attempts to reduce consumption and spending several hours daily either drinking or recovering from effects.
Motivational interviewing and readiness for change
- Appears to be in the contemplation stage, acknowledging his drinking is problematic while expressing ambivalence about complete abstinence.
- James identified his goals as reducing to “social drinking levels” and improving relationships with his children, reporting he uses alcohol primarily to manage stress and loneliness.
Risk assessment
- James denied current suicidal ideation but acknowledged occasional passive thoughts without intent or plan. He reported avoiding driving after drinking as a harm reduction strategy.
- Identified protective factors including stable employment, relationship with his children, and a supportive sister nearby. No formal safety plan currently in place.
Strengths
- Demonstrated insight into his problematic drinking patterns and reported maintaining regular exercise despite drinking habits.
- He described having 15 years of consistent employment, weekly support from his sister, and achieving three months of significantly reduced consumption two years ago.
Assessment and testing
- Based on an AUDIT Score of 24, James was found to be in the High Risk range, indicating a very high level of problematic alcohol use requiring immediate intervention.
- Client has indicated they believe they have a problem with drinking and that they would find it difficult to cut down or stop drinking.
- Further assessment planned includes daily drinking diary.
Treatment plan and next steps
- Treatment goals established include gradual reduction in alcohol consumption, with planned interventions of weekly counselling using motivational interviewing and CBT approaches.
- Referral to GP for potential medication-assisted treatment discussed and accepted by client.
- James agreed to maintain a daily drinking diary and schedule a GP appointment before the next session on 20/05/2025.
