MENTAL HEALTH BIOPSYCHOSOCIAL ASSESSMENT
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REASON VETERAN ENTERED CARE
Veteran’s statement of why they are entering services, level of motivation for change, and reasonable accommodations they may need for service participation:
Veteran was arrested for having drugs 3 years ago. He is in Veterans’ treatment court (VTC) now due to taking so long to charge him with a crime. Veteran is “okay” with completing Veterans’ court and treatment. Veteran is able to adhere to responsibilities without accommodation.
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HISTORY OF CURRENT PROBLEM
Veteran’s current problem, including history, emotional/behavioral functioning, maladaptive/problem behaviors, and adjustment to current disabilities/disorders:
Veteran is currently in VTC for an opiate use disorder. He indicates that the disorder arose from be treated for back pain and using morphine that was prescribed to cope with his pain. Veteran explains that his back pain came from a degenerative disc which has now spread. Veteran states that he is able to pay for his use by “enterprising.” He indicates that he will help deal and distribute to help pay for his opiate use.
Current social stressors:
Veteran states that most of his stress comes from trying to get his bills paid, and his “uncooperative” roommates. Veteran indicates no other stress
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MENTAL STATUS EXAM
Appearance: Veteran dressed appropriate for the weather and for today’s meeting.
Behavior/Attitude: Veteran had appropriate behavior during today’s meeting.
Level of Consciousness: Oriented x3
Alert/Oriented: Oriented x3
Affect/Mood: Veteran was in good spirits in discussion, but had little changes in affect during conversation.
Thought Process/Form: Veteran was able to carry on conversation and form answers to questions.
Insight/Judgment: Veteran showed some mild impairment to his insight on the impact of substance use
Memory: Veteran had difficulty remembering some aspects of his history. Veteran also had some difficulty in remembering dates of events, some dates discussed during the meeting contradicted dates discussed earlier in the assessment.
Attention/Concentration: Veteran was able to concentrate during the meeting, and stayed on topic.
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PAST PSYCHIATRIC/PSYCHOLOGICAL HISTORY
Veteran’s reported history of mental illness and diagnoses, including number of hospitalizations in the last two years, and any medication compliance/side-effect issues:
Veteran explains that he was diagnosed with MDD (Major Depressive Disorder) sometime between (dates omitted). Veteran was taking medication for the disorder, but stopped taking it when he stopped seeing the doctor in (date omitted). Veteran states that he also has some memory problem, which he attributes to his age.
Relevant family history of mental illness and/or substance use disorders:
No history of mental illness. Mother was an alcoholic.
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SUBSTANCE USE/ABUSE AND ADDICTIVE BEHAVIORS HISTORY:
ALCOHOL
Alcohol use, including amount/type/frequency:
No
DRUGS
Drugs of choice used, including amount/frequency:
Opiates (Heroin) and Meth. Veteran uses opiates daily at around 3 to 3.5 grams a week via injection. Veteran has found himself using more than he intended to, and using instead of completing responsibilities. Veteran has a desire to quit and is referred to SUD treatment. Veteran uses meth “off and on”
AGE OF ONSET OF USE
Age of first use (alcohol/drugs) and age when alcohol/drugs became problematic:
See Hx of problem.
TOBACCO
Tobacco use, including how long and how much (cigarettes/e-cigarette/cigars/pipe/chew):
If yes, does Veteran want to quit:
Veteran smokes half a pack a day, and wants to quit. Veteran is not interested in the smoking cessation program at this time.
BEHAVIORAL ADDICTIONS
Behavioral addictions, history and current status:
Veteran denies.
CONSEQUENCES - ALCOHOL/DRUGS/BEHAVIORAL ADDICTIONS:
(PHYSICAL/EMOTIONAL/BEHAVIORAL/SOCIAL/LEGAL/EMPLOYMENT/FINANCIAL)
Veteran states that he now faces legal issues from being caught. Veteran explains that he spends around $400 a month on heroin. Veteran is diagnosed with (physical illness omitted) as a result of IV drug use.
TREATMENT HISTORY:
Last substance abuse treatment attended:
Veteran denies
Number of previous treatments (including total years/months in 12-step or other support groups) and outcomes: Veteran denies
Last period of abstinence from drugs/alcohol and how long maintained:
Veteran is unable to remember
Longest period of abstinence:
Veteran is unable to remember.
Relapse history and factors that contributed:
Veteran cannot determine abstinence to determine relapse factors.
Does Veteran want INFORMATION AND RESOURCES and/or a REFERRAL for treatment:
Yes, Veteran will attend STOP (Substance use Treatment OutPatient) orientation.
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ABUSE/PSYCHOLOGICAL TRAUMA HISTORY
ABUSE/NEGLECT SCREEN
As a child, witnessed or experienced emotional/physical/sexual abuse, neglect or other trauma:
Veteran was aware of his mother alcohol use, but this never caused barriers in his life. Veteran has caught in a fire at a young age, which caused physical health problems. Veteran also explains that he had burning gasoline thrown on him by accident. Veteran states that neither of these events have any effect on him today.
As an adult, witnessed or experienced emotional/physical/sexual abuse, neglect or other trauma:
Veteran denies any abuse as an adult. Veteran states that he was hit in the head once by a liquor store own on his 21st birthday, but has no lasting effects in his life.
Ever been abusive towards others, past or present:
No
INTIMATE PARTNER VIOLENCE (IPV) SCREEN
Are you in a situation where your current or former partner is calling you names, or has treated you in ways that make you feel uncomfortable, afraid or powerless:
n/a
Have you recently been hit, kicked, pushed, strangled, threatened or otherwise hurt by your current or former partner:
n/a
In the past 12 months, have you used, or felt at risk of using violence with an intimate partner
n/a
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HISTORY OF HARM TO SELF/OTHERS
Risk or protective factors for harm to self/others:
n/a
Does Veteran participate in/practice any risky behaviors that could jeopardize their personal safety:
Opiate use. Meth use.
Imminent risk and safety plan if present:
Attend STOP orientation. Discuss inpatient treatment.
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CHILDHOOD/DEVELOPMENTAL HISTORY
Chosen gender expression and sexual orientation:
Male, veteran requested not to answer at this time.
Developmental/social history:
None
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CURRENT SIGNIFICANT RELATIONSHIPS
Veteran-identified peer group/support system:
Veteran has friends that he is able to rely on that he states are “pretty darn close.” Veteran indicates that it’s easy for him to make friends. But he has been sticking to himself lately.
Marital/intimate partner history and current interactions with current/former partners:
Veteran has never been married and has been in two relationships. One relationship ended due his partner’s use of drugs. His second relationship ended because he could no longer see himself “while being with him.” Veteran states that he was able to stay friends with his second partner until he passed away.
Children, including number/ages/current relationship/level of engagement, and any formal/informal support being provided (financial/childcare/other support):
n/a
Experienced loss/grief related to significant relationships:
Veteran states that he was sad when his former partner passed away, but is “okay” now.
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ACADEMIC/EDUCATIONAL
Academic history, including highest grade completed, current engagement with school/vocational training, and educational goals:
Veteran has a High School Diploma from (high school omitted) and has attended some college at (college omitted). Veteran states that he had an IQ of 135 in high school. He found his classes easy, and has no educational goals at this time.
Barriers to learning (visual/hearing/mobility/cognitive/other barriers):
No barriers
Patient reports that he/she can read (good/fair/poor/unable): Good
Patient reports that he/she can write (good/fair/poor/unable): Good
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EMPLOYMENT HISTORY(LAST 5 YEARS)
Current employer/position/title, vocational services, and employment goals:
Unemployed. Veteran wants to find something to occupy his time.
Barriers to gaining and sustaining employment, including vocational services needed:
Veteran states that he works for about two weeks before his back problems occur and he is unable to do anything.
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LEGAL PROBLEMS
Does Veteran currently have a guardian:
No
What legal issues need to be addressed, including urgency, impact on current issues, and influence on care/treatment/services:
Veteran is facing charges for possession of controlled substances.
Ever arrested and/or incarcerated, including total time, charges/crimes, and dates:
Veteran was arrested once for current charge, and spent one night in jail.
Child support enforcement status:
n/a
Registered sex offender:
No
Probation/parole status and date supervision ends:
Veterans Treatment Court
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MILITARY HISTORY
Branch, Military Occupation Specialty, and highest rank: Army, Artillery, E3
Theater of Operation: n/a
Combat/hostile fire exposure: None
Years of service and discharge disposition: (years of service omitted), Honorable discharge
Disciplinary actions: None
Service-Connection: None
Does Veteran meet screening criteria for the depleted Uranium, Gulf War OIF, Ionizing Radiation, or Agent Orange Environmental Registries: No
If yes, Veteran was encouraged to contact Comp and Pen Office: n/a
Military Sexual Trauma: None
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SPIRITUAL/CULTURAL ISSUES
Primary spiritual/religious preferences, and any spiritual/religious issues that Veteran wants to address, including attitudes in Veteran’s culture or religion related to seeking help for mental health or substance abuse problems:
Veteran considers himself spiritual but does not identify with a religion.
Self-identified Veteran ethnic/cultural identity and importance of ethnic/cultural identity as a component of treatment:
Caucasian
Language preference and languages spoken:
English
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RELEVANT MEDICAL HISTORY
Veteran-identified medical issues, including willingness/ability to engage in medical treatment and follow a medical plan of care:
Veteran has degenerative back issues. Veteran has some hearing loss, and respiratory problems. Veteran has been diagnosed with (physical illness omitted) and a swollen prostate.
Do any of Veteran’s current medications positively or negatively impact their mental health issues:
Veteran is not on medications at this time
Is Veteran using any complementary health approaches:
None
Is Veteran voicing pain, any emotional/behavioral/physical impact of pain, or follow-up needed:
Veteran voices back pain at this time at a 4. Veteran states that that if it gets too high “it shuts me down” and he is unable to get out of the house without assistance.
Is Veteran able to manage their activities of daily living (ADLs):
Yes, when back isn’t hurting.
Is Veteran pregnant or breast-feeding:
n/a
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HEAD INJURY HISTORY/TBI
Veteran is diagnosed with a TBI or reports injuries that could have resulted in a TBI:
Veteran has never been diagnosed with TBI. Veteran been hit with an axe handle, wrecked on a bike, “hit a couple windshields,” and been around artillery concussion blast.
Veteran reports current symptoms that could be TBI-related:
Memory loss and Loss of consciousness
Medical evaluations and/or reasonable accommodations needed/requested:
Veteran will establish a primary care provider to discuss issues.
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LEISURE ACTIVITIES/HOBBIES
Veteran-identified enjoyable leisure activities and any barriers to participation:
Drawing, Painting, Cooking, watching tv, and playing with dogs.
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NUTRITION
Access to food, current use of Food Stamps or food pantry assistance, and food resources provided:
$15 in EBT. Veteran is able to get one meal a day and snack throughout the day.
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HOUSING
Veteran’s report of where they have been living for the last 90 days (HOMELESS = living in a shelter/car/camp or on the street) and housing barriers (evictions/past-due utilities/pets):
Veteran owns his property at (address omitted) where he pays $300 to the previous owner. He can be reached at (phone number omitted).
Is Veteran’s current living environment safe/unsafe, supportive/hostile, etc.:
Safe and supportive.
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TRANSPORTATION
Current means of transportation, eligibility for VA travel and/or travel pay, and transportation needs:
Veteran’s roommates provide rides and he is able to take the bus. Veteran has a valid driver’s license.
If Veteran has a vehicle, is it currently on VA property:
n/a
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FINANCIAL STATUS
Household income, debts and financial goals:
Veteran receives SSDI. Veteran currently owes on his home.
Does Veteran have a payee or conservator:
No
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ADVANCE DIRECTIVES
Veteran has an advance directive: No
Veteran requested help with completing or updating an advance directive and assistance was provided: Not interested
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DIAGNOSTIC IMPRESSION:
Veteran meets criteria of Opiate Use Disorder (OUD) per DSM V, his use has had undesired impacts in his life, he has found himself using more than he wanted to, and has found himself choosing to use instead completing responsibilities. Veteran does not meet DSM V criteria for MDD at this time.
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INTERPRETIVE SUMMARY, INCLUDING STRENGTHS AND BARRIERS:
Veteran’s OUD is affecting his life financially and legally. Veteran is able to understand what he needs to do and is able to articulate his issues to the court and to the VA very well. This will help him in being successful by allowing providers to treat him correctly. Veteran has barrier of low income, in which his OUD takes a good portion of his funds. Veteran will discuss with providers the impacts if use.
Created 5/4/16