Potomac

Behavioral
Therapy
Cumberland Maryland

Brittany Harpster
December 8th, 2021
Jason Gaither
Human Services 207
I. Introduction to agency

Potomac Therapy, located at 249 Henderson Avenue in Cumberland MD, provides:

 mental health and substance abuse therapy

 occupational therapy
 primary care
 psychiatric services
 on-site lab collection
 medication management

My Responsibilities as an intern at this facility include Observing One on one counseling

sessions, assisting in filling out client evaluations and other documentation such as session
notes.

Client Assessment
“D” is a 32-year-old male who attends bi-weekly counseling sessions at Potomac behavioral
therapy, “D” was referred to Potomac therapy by the Psychiatric unit at the hospital. “D”
was diagnosed with the following: Bipolar, depression, anxiety, and substance abuse. “D” is
currently prescribed Quetiapine (Seroquel) (for mania and bipolar depression), Klonopin
(clonazepam) (for anxiety) and Suboxone (for substance abuse)
“D” does not have a very large support system and does not speak to his mother or father
or little brother. His main supports consist of his boyfriend and grandma. “D” has been
struggling with substance about for approximately 4 years and states that it began when he
came out as homosexual to his very religious family. His family did not except him and
began to treat him differently, in which he started having manic episodes and began using
heroin. Which then, left him homeless and he also lost his job and ended up being
hospitalized during his manic episode.
“D” is a polite person, with great manners. “D’s” goals are to find a home, get a job and
continue medication to control his mental health issues and substance use. Potomac
Therapy is working with “D” on his goals and trying to find a temporary home placement for
him until he gets back on his feet.
1. PHYSICAL HEALTH/NUTRITION/MEDICATION
“D” is compliant with his treatment and medication and uses Potomac’s Primary care
doctor for his medications and takes them as intended as well as the suboxone.

2. PHYSICAL SELF CARE

 “D” appears well-groomed, clean, and neatly dressed. “D” has the ability to take care of
his personal hygiene without assistance.
3. INSTRUMENTAL ACTIVITIES OF DAILY LIVING
“D” is able to complete his own cooking and cleaning as well as making sure he takes his
medication on time. He is also willing and able to work and drive although he does not
have a vehicle currently.
4. EMOTIONAL STATUS
“D” was diagnosed with bipolar disorder (manic), anxiety, substance abuse disorder and
depression. Psychosocial and environmental stressors include, not having a stable
relationship and not speaking to his parents and sibling. He also, is homeless and jobless
and that is the main source of his stress.
SOCIAL RESOURCES
“D’s” only interactions that he has is between his grandmother and current boyfriend.
So, his social resources have been recently limited.
5. FAMILY HISTORY
“D” grew up in Delaware with his mother, father, and younger brother. He said that he
had a good life growing up. His family is largely religious Christians and base their lives
surrounding their religion which is another reason that “D” wished not to speak to
them.
6. FINANCIAL STATUS
“D” was working at the dollar tree before his manic episode and living with his ex-
boyfriend but currently is unemployed but working hard on getting employment.
7. ENVIRONMENTAL SITUATION
“D” goes from couch to couch and is hoping to get a place with his boyfriend as soon as
he gets a job. “D” visits his boyfriend at the boyfriend’s moms house and sometimes
stays there.
8. EDUCATIONAL BACKGROUND/HISTORY
“D” graduated high school but has not attempted college and doesn’t seem interested in
doing so in the future.

9. EMPLOYMENT HISTORY/HOBBIES/VOLUNTEER EXPERIENCE

 “D” has only ever worked at the dollar tree, however he worked there for about 5 years
prior to being let go. “D” enjoys drawing and taking walks and spending time with his
boyfriend.
10. SPIRITUAL/RELIGIOUS BACKGROUND AND RESOURSES

“D” has a very strong hatred for religion because of his families very strong beliefs and
ultimately the reason that his family disowned him after coming out as homosexual.

II. PROBLEM LIST

1. Unemployed
2. Substance abuse
3. Homelessness

III. ASSET LIST

1. Genuine and Kind

2. Goal driven
3. Great sense of humor

IV. CLIENT GOALS

1. Unemployed: “D” is currently working with a case working and is putting in

applications for employment.
2. Substance Abuse: The goal is to abstain from heroin and continue taking his
suboxone as prescribed.
3. Homelessness: “D” is working with Potomac and his case worker to find a place to
stay that is stable housing for him until he starts working.

V. SERVICE/TREATMENT PLAN
 GOAL #1 “D” is continuing to turn in applications for employment and working along
side his case worker to complete a resume.
GOAL #2 “D” states that he plans to delete old contacts that might trigger him to use
and continue to go to therapy to talk about the issues with his family so that he can
remain stable and not want to use.
GOAL #3 “D” will continue to work along side Potomac and his case worker to find a
place for him to stay. He stated that he wants to talk to an apartment building owner
and see if there is something the man can work out with him. So, he will be going to
speak with him.

VI. RESULTS OF SERVICE/TREATMENT TO DATE

GOAL #1 “D” has gained employment and has been attending work every day and might
look for a second job at this point to gain more money.
GOAL #2 “D” has continued to take his medications as prescribed, and his urine analysis
has come back good for the last few weeks.
GOAL #3 “D” has moved in with his boyfriend now that he is employed and plans to stay
there for a while.

VII. RECOMMENDATION FOR NEXT STEP

1. “D’s” counselor will check on him frequently to make sure that he is doing okay
mentally and keep him accountable for attending work
2. “D” will continue his bi-weekly Urine analysis and attend NA meetings at least twice
a week.
3. “D” will continue to work and start a saving account so that he doesn’t have to
worry about losing his home or getting behind.