k Local Charities Substance Abuse Treatment k
Name: Michael Francis ByrnesDOB: 5/19/1978 / Client number: 10408
Date of Initial Contact: Dec 1, 2011 / Date of Evaluation: Dec 1, 2011
Primary Counselor: Barbara Jackson, CSAC
Address:
c/o Catherine Daniels
14 Court Place
Some Town, YY 12345 / Phone:
(111) 222-3486 (Catherine Daniels)
Collaterals:
Catherine Daniels, sister
Allen Werther, friend / Diagnosis:
Polysubstance abuse, Schizophrenia
Referral
Mr. Byrnes was ordered into treatment as a term of his probation upon release from Any County Jail.
Michael F. Byrnes is a thirty-three year old African American male. He is a military veteran with a long history of substance abuse prior to enlistment and since his discharge. Mike is very uncomfortable and fearful around people. He has been diagnosed with Schizophrenia from Any County Jail and County General Hospital.
Much of the information for this evaluation was obtained from his sister Catherine Daniels or with her encouragement.
Current Substances of Abuse
Mr. Byrnes prefers opiates including heroin, oxycontin, and methadone. It is difficult to ascertain amounts, as Mr. Byrnes often gets confused when asked direct questions. He says that these drugs make him less afraid and help him to think a bit more clearly. He prefers intravenous use. He says, “It stops the noise in my head.”
Heroin and other opiates clearly have a calming effect on him and sometimes help to alleviate some of his hallucinatory symptoms.
Personal and family history suggest that Mr. Byrnes has a long history of alcohol use, but his current use is intermittent based on lack of access.
Substance Use History
Age of Onset
Alcohol age 11
Marijuana age 14
Heroin age 16
Mr. Byrnes says that his parents did not notice his alcohol use when he was in middle school because they were such heavy drinkers themselves. He began to use marijuana regularly and to experiment with heroin during high school.
He claims that he did not use any drugs when he was in the Army, but admits to continued use of alcohol during that time. He returned to use of opiates after his discharge from the Army. He tried Methadone treatment, but he claimed the program was too far away.
In regard to stimulant drugs, he admits to experimenting with these during high school. He insists that after minimal use, he avoided these drugs because, “They’re bad news.”
Mr. Byrnes acquired Hepatitis C after his discharge from the Army, likely from contaminated works. He continues to prefer intravenous opiate use.
Heroin and other opiates clearly have a calming effect on him and sometimes help to alleviate some of his hallucinatory symptoms. Personal and family history suggest that Mr. Byrnes has a long history of alcohol use, but his use is intermittent based on lack of access.
Family History of Substance Use
Mr. Byrnes and his sister Catherine report that both parents were alcoholic. Catherine claims to abstain from alcohol and all other drugs. Mr. Byrnes describes his other two sisters as “worse than I am.” Ms. Daniels agreed that her sisters drink heavily and use a variety of other drugs.
Participation in Self-Help Programs
Mr. Byrnes is vague about whether or not he is currently attending AA or NA. Given his discomfort around other people, it is unlikely that he does attend.
Previous Attendance: When on probation he was required to attend. Any County Jail records indicate attendance, but little participation.
Detox and Other Substance Use Treatment (outside this program).
County Methadone Treatment Program: November 2007-January 2008
Legal History
Arrest for possession of marijuana, age 18; adjourned in contemplation of dismissal.
Arrest for possession of heroin and drug paraphernalia; completed Probation, March 2008.
Various arrests for trespassing and other minor crimes.
His previous probation officer has communicated that Mike’s parents were very well respected in the community and that both law enforcement officers and judges have made every effort to help Mike.
Health Issues
Hep C; complains of headaches, possible TBI. General health appears to be poor. Referral for a full medical examination should be made.
Psychiatric History
Diagnosed with PTSD after last deployment. Current diagnosis of co-occurring schizophrenia.
He has been hospitalized at County General Hospital for mental illness crises. He was also treated at Any County Jail mental health services.
Family Background
Mr. Byrnes is single and has never been married. He has not had any significant relationships.
Mike comes from an intact family, his parents never having divorced. He has three sisters. His parents died in a car accident in 2003. He describes his father as physically abusive.
Since his parent’s death, he has had little contact with any family with the exception of his sister Catherine. Catherine claims that Mike gets very aggressive from time to time, usually because he is fearful that others are trying to hurt him or others.
Education
Graduated high school, but describes having difficulties with learning.
Work History
Since discharge, he has had a variety of odd jobs, only for a few weeks at a time.
Military History
Honorable discharge, June 2006; 2 deployments in Iraq.
PlanWeekly urine screens, weekly group sessions and individual sessions
Re-assess in 60 days
33 Third Street, Phone: (111) 323-3223
Some Town, YY 12347 Fax: (111) 323-3224