2016
January 2016 I drank some rat poison and attempted to commit suicide again an ambulance brought me to the Palmer emergency room. Escaped and made it back to Warren. Warren police officers came and brought me back to the emergency room and on that drive we talked about their dashcam and in vehicle recording system that they had gotten. I told that officer how Springfield police officers denied me medical attention and I caught ADA Johnston providing a fake receipt to the courts all because that driver did not have car insurance and she was driving with a suspended registration and had a rejection sticker for safety. I told that officer that this driver had a sister in the district attorney's office and had friends that were police officers
At some point getting out of the psych ward January 25 and being forced and depleting guilty February 5. I was went to a scheduled for a meeting at my lawyer, Elaine Pourinski’s office in Northampton And when I showed up, a man and older gentleman pulled out of small hammerless revolver, and placed it to my forehead and took the files that Elaine Pourinski had asked me to bring that day. He told me not to pursue this case and I was a complete disaster and I didn’t know what to do. When I walked into Elaine Pourinskis office, I was a complete wreck and she told me there’s nothing she can do and she doesn’t want me calling the cops, She told me she’s having knee surgery and she’s worried for her safety and Her family safety. I thought obligated to stay quiet, Plus, I felt like a complete disaster because I was so sick at the time and barely holding it together as it was. Obviously, looking back I know this is a complete setup and she was just playing stupid because she knew I was sick. All these court appointed lawyers are scum and I’m gonna prove it. I’ve got years worth of data to track.
Discharge Summary/Transition Plan
Person’s Name (Last, First MI): Record #: Date of Admission:
Stebbins, Richard 158539 02/29/2016
DOB: Gender:
Organization Name/Program Name: Advocates, Inc./ 10/08/1978 Male
Outpatient
fl Transition - From (Unit/Program): To:
{) Discharge
Last Contact: Discharge/Transition Date:
2/29/16
Person’s location and contact information post dischargeftransition:
Wdress: El Unknown
176 B South Street Warren MA
Felephone: 4139491925 fl Unknown
f discharged to shelter, document efforts to prevent:
NA
Status at Last Contact:
Client on probation through Worcester Superior Court Probation Department
Client is on waiting list for therapist and is currently being seen by doctor for psychiatric medications
Summary of Services/Treatment Provided (consider vocational, educational, financial, legal, medical, behavioral and risk status):
Client seen for evaluation only
)utcomes (Include qualitative and quantitative informabon regarding progress/gains achieved, rengths, abilities and
preferences. Specify any standardized measures used):
Health and Safety Concerns (include behavioral, medical and/or substance use issues): U Not applicable
Client has multiple suicide attempts- most recent one in January
Status Towards Meeting Goals:
Dverall Progress In Treatment:
Diagnosis At Intake
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 D08 10/8/1978 Page # 1
[primary Diagnosis IlDiagnosis Type Code/GAF [Narrative Description
Yes DSM-5 (lCD-b) F33.1 Major depressive disorder,
Recurrent episode, Moderate,
No DSM-5 (lCD-to) 765.3 Problems related to other legal
circumstances,
Lowest GAF in Past Year(If Known):
Diagnosis At Transition/Discharge
:Primary Diagnosis IDiagnosis Type Code! GAF Narrative Description
Yes DSM-5 (lCD-b) F33.t Major depressive disorder,
Recurrent episode, Moderate,
No DSM-5 (lCD-b) 765.3 Problems related to other legal
circumstances,
Highest GAF in Past Yearçlf Known):
Reason for Discharge or Transition:
Other
If other, please explain
Client is on waiting list for therapist
Currently has doctor to prescribe psychiatric medications however is not currently taking them.
Lf involuntary/administratively discharged, summary of action taken: Not applicable
erson Served notified of appeal process (explain)
Person’s Response to Treatment and Transition! Discharge:
Medications as Reported by Person at time of Discharge/Transition:
J None Reported
Referred To (Agency/Program Name, Location, and Contact For (describe services/supports, rationale, list bate(s)/Time
Information): dates/times of appointments if known): (s) of Appts. If
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page #2
I Known:
L_____________
ftercare Options (Include information on symptoms person should watch for, options available if these symptoms recur or additional service
needed, and/or follow-up plans):
Client is aware of how to contact emergency services should emergency arise.
Also see recommendation letter
Was person provided copy of Transition/Discharge Plan? No Person did not receive copy
If no, please explain:
Signature Sheets
Signature Role Namelfltle Degree License Date Signature
MCI Clinician Ushinski, Lukas MSW LICSW 7/28/2016 Password Authenticated
BR - WISR CLINICAL SUPERVIOSR
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page #3
Individualized Action Plan
‘erson’s Name (Last, First MI): Record #:
Stebbins, Richard 158539
DOB: Gender:
Organization Name/Program Name: Advocates, Inc./ Outpatient 10/08/1978 Male
Date of Admission: LI Annual lAP-Date: fl Revised lAP-Date:
02)29/20 16
This Section Mandatory For Outpatient Substance Use Counseling Only(Check Here if Not Applic& Piifl
Medications as Reported Dy the Person Served on Date of lAP Development -
J None Reported
Medication Name Dose Plans for Change - Including Prescribed by
Rate of Detox
Dther Agencies/Community Supports and Resources Supporting Individualized Action Plan:
[El None Reported H No Change
Transitionltevel of Care Change/After careIDischarge Plan: [E No Change
DAnticiPated Date:
Agency Name: Contact and Title
:riteria - How will the provider/individual/parent guardian know that level of care change is warranted? (Check All that Apply):
fl Reduction in symptoms as evidenced by:
Services Currently
Provided
Release Signed
H Attainnent of higher level of functioning as evidenced by:
LI Treatment is no longer medically necessary as evidenced by:
LI Other:
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOG 10/S/I 978 Page # I
Plan Completed by (Name, Title, Program):
Ushinski, Lukas, BH - WISR CLINICAL SUPERVIOSR
Was the person served provided copy of the lAP? No Reason;
Seen for evaluation only
Signature Sheets
Signature Role Name/Title Degree License Date Signature
MCI Clinician Ushinski, Lukas MSW LICSW 7/28/2016
Password
Authenticaind
81-I - WISR CLINICAL SUPERVIOSR
Richard Stebbins Record #158539 ClientNo #156720 Clairutrak #56813 006 10/8/1978 Page #2
Adult Comprehensive Assessment
Person’s Name (Last, First MI): Record #: Date of Admission:
Stebbins, Richard 158539 02/29/2016
DOB: Sender:
Organization Namef Program Name: Advocates, Inc./ Outpatient 10/08/1978 Male
Comprehensive Assessment Date: 02/29/2016
Presenting Concerns (In Person’s Served/Family’s Own Words)
Referral Source:
Worcester Superior Court Probation Department
Reason for Referral:
Client has condition of probation to complete a mental health evaluation
What Occurred to Cause the Person to Seek Services Now (Note Precipitating Event, Symptoms, Behavioral and Functioning Needs):
Probation began: February 5, 2016
Probation ends: February 2017
Offense: forgery
- Living Situation
What is the persons current living situation? (check one)
Person’s Home:
Residential Care/Treatment Facility:
Other:
apartment- living with wife
t Risk of Losing Current Housing No Satisfied with Current Living Situation Yes
Comments (Include environmental surroundings and neighborhood description):
Family History
Family History and Relationship, Parental/ Familial Caretaker Obligations:
Parents: Client age 21 when parents divorced - just didn’t get along.
Mother in Springfield, MA- talk to her couple times a week, see her every few weeks. Described as good’
Father in West Warren, MA- talk to him couple times a week, see him couple times a week, Described as “good”
Younger brother and sister- brother lives in Munson, MA and every couple weeks talks to week. Sister lives in Springfield with mom,
Samantha 19- haven’t seen her since 2002. Mother wanted to raise child on own and then didn’t have to pay child support and was already
having hard time seeing her,
Nathan 16- Never seen him. Didn’t get a long with mother- just a fling. Does not pay child support.
Dietrich born 2003 - haven’t seen since 2004. Child with ex-wife and she ended up marrying a friend of his and he ended adopting him. No
child support.
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page # 1
First wife- marrIed 4 years- reason for divorce - didn’t get along anymore and went separate ways. 2000
2011- current marriage. No children reported.
Married
Pertinent Family Medical, MH and SU History:
Denies any substance abuse hx in family.
Mother- depressions. Doesn’t know if she is on medications
Developmental History and Status:
Putnam High School in Springfield, MA graduated.
Denies any special education classes or dx with a learning disorder.
Denies any AD/HD dx.
Ritalin- 2nd or 3rd less than 6 months. Didn’t help.
Social
Support
Friendship/Social/Peer Support Relationships, Pets,Community Supports/Self Help Groups: (M, NA, SMART, NAMI, Peer Support,
etc.):
8 friends - talk to them or see them every couple of weeks.
Never attended M/NA
Religion/Spirituality and Cultural/Ethnic Information:
Catholic
Does not currently practice
Caucasian
Legal
Status and
Legal
Involvement and History
Does Person Served have a Legal Guardian, Rep Payee or Conservatorship? No
If yes, complete and attach the Legal Status Addendum
Is there a need for a Legal Guardian, Rep Payee or Conservatorship? No Explain:
Does the person have a history of, or current involvement with the legal system (i.e., legal charges)? Yes
If yes, complete and attach the legal Involvement and History Addendum
Education
Highest Level of Education Achieved:
HS Grad
Highest Grade Completed: COL - Some college credit/no degree
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOS 10/8/1978 Page #2
Person’s Preferred Learning Style(s):
Learn by doing,Verbal,Visual,Written,Auditory
Currently Enrolled in Educational Program? No
Is person interested in further education or assistance in education? Yes
If the answer to either of the above questions is yes, complete and attach the Education Addendum.
Employment and Meaningful Activities
Employment Status/Interests:
fl Never Worked Currently Employed? Yes If yes, length of employment:
Advantage Sales and Marketing- part time currently
(If not currently employed) — Person served wants to work? / Comments:
Does the person want help to find employment? Yes If yes, complete Employment Addendum
Comments:
Meaningful Activities (Community Involvement, Volunteer Activities, Leisure/Recreation, Other Interests):
Additional Information:
hiking, fishing, bike riding and gym, reading
Income/Financial Support
How does the person describe her/his current financial situation?
Occasional struggle with finances
Comments:
Sources Of Financial Assistance Amount
biIit No
FoodStamps No
SSDI No
LS51 No
Contributions from family or friends No
Child Support No
erans Benefits No
Richard Slebbins Record #158539 ClieniNo #156720 Claimtrak #56813 006 10/8/1978 Page #3
TAFDC No
EAEDC No —]
Other
Other
Military Service
None Reported - If None reported, skip to the Substance Use / Addictive Behavior History Section
Military Experience: Date of Discharge:
None
Type of Discharge
Reason:
Is a complete Military Service Asssessment needed? No If yes, complete and attach Military Service Addendum
Addictive Behavior and Substance Abuse History
Does person report a history of, or current substance use or other addictive behavior concerns (i.e., alcohol, tobacco, gambling, food)?
Yes
If yes, complete and attach Addictive Behavior History/SA Addendum.
Mental Health and Addiction Treatment History
Type of Service ervice Dates of Service Reason Name of Inpatient! ompleted
Provider/ utpatient
4gency I
Efficacy of past and current treatment:
Psychiatric History (including past diagnoses):
5 psychiatric Hospitalizations
1- 2005 Springfield Baystate medical Center- drank a gallon of vodka- 2 weeks in psych ward because suicide attempt. Had caught wife
cheating on him. Prozac and
2-2005 Depakote Carbitral prescribed. Less Uien 6 months- suicide attempt again, pills and alcohol. Sister had brought him to hospital - 2
week stay.
3- last year October Caught wife cheating on him. Cut self on left forearm, Wife had called ambulance. She had text him and he said
goodbye so she called police. Mary Lane, Ware Hospital- there for 3 days. Was prescribed medications Lithium was one of them - maybe a
few others. took them while at hospital but then stopped after.
4- December- Wing Memorial in Palmer - right before Christmas- taken a bunch of pills, Ativan. Was prescribed to him. Wife noticed
breathing was off and something off. 4-5 days in hospital. Cave irregular heartbeat. Day and half in psych ward then let go. The stress and
anxiety of wife cheating.
Richard Stebbins Record #158539 ClienINo #156720 Claimtrak #56813 DOB 10/611978 Page #4
5-January another week In psych ward. Wing Memorial In Palmer. Drank rat poison- wife wanted to talk. So In-between she called the ps
and the cops took him to emergency room.
Is not on medication now.
Memory problems.
Randomly maybe 3 or 4 times.
Not helpful.
BHN- was seeing
Went for months- Every other week
never weekly.
Denies any outpatient substance abuse counseling.
Denies any detox admissions
Couples counseling- she was supposed to schedule something.
Anxiety- October 2015 started last year.
Suicidal thoughts as a teenager.
Griswold Center- Palmer- prescriber and therapist.
still setting up date for therapist.
Source(s) of Information:
Person served
If other, p!ease explain
Physical Health
ame and 5peciaity Address ffice Phone !flx pate of Last Exam
redentials Li H H
Physical Health Summary OR U Refer to Attached Physical Health Assessment
Bureau of Substance Abuse Services (BSAS) Programs must complete the MSDP Infectious Disease Risk
Addendum and the BSAS TB Assessment
Is this person involved in a BSAS Program? Yes
If yes, complete and attach the Infectious Disease Risk Assessment and the TB Intake Form
Allergies:
Food:
No Known Allergies
Medication:
No Known Allergies
Environmental:
No Known Allergies
Richard Stebbins Record #158539 ClientNo #156720 claimtrak #56813 008 10/8/1 978 Page #5
Physical Health Summary: (Include health history, chronic conditions, significant dental history, and current physical complaints that may
interfere with the person’s served functioning.)
Denies any T8I where lost consciousness
Denies any seizure disorders
Denies any heart problems- irregular heartbeat caused by Ativan
Sexual History/Concerns:
Pain Screening:
Does the person experience pain currently? Yes
Has the person experienced pain in the past few weeks? Yes
Describe the type, frequency, duration, intensity, identified cause, any limitations to functioning and what helps relieve the pain:
Muscle myapathy
missed some appointments from being in hospital.
Multiple times a day.
Nutritional Screening: (check all that are reported)
Special Diet? (e.g. diabetic, celiac)
Additional Special Diet information:
Follows Special Diet?
Beliefs, perceptions, attitude, behaviors regarding food:
Physical Health Summary and Recommendations:
If person has not had physical exam in past year, or if person has reported pain without a determined cause, or if person has reported eating
disordered behaviors that are not being medically followed:
Reason person declined exam:
Medication Summary
Medication Information (Include All Non-Psych Meds/Prescription/OTC/Herbal)
L] None Reported
Medication Information and history of adverse reactions: (Include what medications work well and have worked well previously, any
adverse side effects, why person doesn’t take meds as prescribed and/or which one(s) the person would like to avoid taking in the future):
Richard Stebbins Record #158539 ClientNo #156720 Clairntrak #56813 DOS 10/811978 Page #6
Does not know if has any adverse reactions to medications.
Advanced Directive:
Does the person have advanced directives established No
If yes, what type?
If other, please explain
If no, does the person wish to develop them at this time? No I If yes, follow agency’s procedure for completion
Trauma History
Does person report a history of trauma? No
Does person report history/current family/significant other, household, and/or environmental violence, abuse or neglect or exploitation?
No
If the answer to either of the above questions is yes, complete and attach the Trauma History Addendum.
Mental Status Exam — (WNL = Within Normal Limits) (**) — If Checked, Risk Assessment is Required
Appearance/Clothing: WNL
Eye Contact WNL
Build WNL
Posture WNL
Body Movement: WNL
Behavior: Cooperative
Speech: Clear
Emotional State-Mood: (in
person’s words): WNL
Emotional State-Affect: WNL
Facial Expression: WNL
Perception WNL
Hallucinations -
Richard Stebbins Record #158539 ClientNo #156720 Clairntrak #56813 DOB 10/8/1978 Page #7
Thought Content: WNL
Delusions - None reported
Other Content -
Thought Process WNL
Intellectual Functioning WNL
Intelligence Estimate - Average
Orientation: WNL [Disoriented to:
Memory: ]WNL mpaired:
Insight: WNL
Judgment: WNL Impaired Ability to Make Reasonable
Decisions:
Past Attempts to Harm Self Self**
or Others:
If other, please explain
see mental health section
5 reported suicide attempts
Self Abuse Thoughts: None reported
If other, please explain
Suicidal Thoughts: None reported
Aggressive Thoughts: None reported
Comments:
r Person’s Served Strengths/Abilities/ Resiliency
(Skills, talents, interests, aspirations, protective factors)
Personal Qualities: (Examples: open, friendly, likeable, friendly
engaging, motivated, loyal, resourceful, caring,
thoughtful)
Living Situation: (Examples: has maintained long-
term stable housing, gets along with living
companions) -
FinancialfEniployment/Education: (Examples: I
graduated F-IS, attended college, currently working, hx
graduated F-IS, some college
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page # 8
of working, multiple work skills)
Health: (Examples: consistent good health, exercises actively addressing health issues
regularly, self cares for health issues as directed by
physician, eats nutritional foods)
Leisure/Recreational/Community Involvement: hiking, reading, bike riding, gym
(Examples: plays a sport, belongs to social group,
attends gym, volunteers for Red Cross)
Natural Supports: (Examples: Family members,
clergy, close friends, neighbors, advisors)
I Spirituaiity/Culture/Religion: (Examples: enjoys
religious services, participates in cultural events,
meets regularly with rabbi)
Assessed Needs
Li If checked, agency’s functional assessment should be completed
turrent Need Group ‘turrent Need Area !lDesires Change YIN
Mental Health/Illness Management-Behavior Depression/Sadness Yes
Management
Evidenced By: hx of S suicide attempts- most recent December 2015 and January 2016, hx of psych medications, hx of psych hospitalizations
Legal Legal Issues Yes
Evidenced By: on probation
Additional Addendums
Select Additional Addendums Needed to be Attached:
Addictive Behavior and Substance Use History Addendum,Legal Involvement and History Addendum
Clinical Formulation - Interpretive Summary
This Clinical Formulation is Based Upon Information Provided By (Check All that apply):
Person served
If otner, please explain
Interpretive Summary: What in your clinical judgment are the need areas, the factors that led to the needs, and your plan to address them?
Limits of confidentiality reviewed. Release of information signed.
See recommendation letter in chart.
Meets DSM 5 criteria for Major Depressive Disorder, Recurrent Episode Moderate
Further Evaluations Needed:
Medical, Psychiatric
If other, please explain
Client has medical disorder and is actively addressing it.
Client has psychiatric appointment set up in March to see medication prescriber. Also is waiting to be assigned a therapist
Richard Stebbins Record #158539 ClieniNo #156720 Claimtrak #56813 00810/8/1978 Page #9
Patient Stress Questionnaire
Was Outcomes tool administered? Yes if Yes, specify:
Diagnosis:
Primary Diagnosis [Diagnosis Type [ode/GAF [[Narrative Description
Yes DSM-5 (lCD-b) F33.1 Major depressive disorder,
Recurrent episode, Moderate,
No DSM-5 (lCD-b) Z65.3 Problems related to other legal
circumstances,
Ranking urrent Need Group Current Need Area Active/Person Declined!
I DeferredlReferred Out
1 Mental Health/Illness Management- Depression/Sadness
Behavior Management
Referred Out
Rationale: Assessed need to be
get appointment by April 1
addressed by therapist (currently on wait list to be seen) Client is come back to meet this clinician if unable to
2 Legal Legal Issues Referred Out
Rationale: Assessed need to be addressed by probation officer
Person’s Service Preferences, Level of Care/Indicated Services Recommendation:
Outpatient Treatment
Person Served/Guardian/Family Response To Recommendations:
Next Appointment: Date & Time:
Date of Service Provider Loc. Code Prcdr. Mod 1 Mod 2 Mod 3 Mod 4 Start Time IStop Time Total Diagnostic
Number Code Time Code
02/29/2016 3941 Norcester 16 10am 11am 1 hour F33.1,
Re-Entry 65.3
Prioritized Assessed Needs:
(If declined/deferred/referred out, please provide rationale)
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page# 10
Legal Involvement and History Addendum
Person’s Name (Last, First MI): Record #: Date of Admission:
Stebbins, Richard 158539 02/29/2016
DOB: Gender:
Organization Name/Program Name: Advocates, Inc.! Outpatient 10/08/1978 Male
Legal Involvement and History Addendum
Legal Charges Designation tatus utcome Begin Date End Date 1 Incident
I Description
Other Adult Open past adult charges malicious damage
to motor vehicle-
she hit client and
did not have
insurance. Siter
and cousin who are
police officer.
Forgery - court
order placed in
mailbox. Access to
Clis and to see that
she was driving
without insurance
that day.
Did not serve any
time.
Name and Phone Number of Court (if applicable):
Worcester Superior Court Probation Department- Anthony Gigliotti
Relationship Sub-Relationship IlName ffice Phone ell Phone
Mama and Phone Number of Probation! Parole Officer (if applicable):
Domestic Relations Court Involvement (i.e., Custody, Protective Services, Restraining Order):
Current Yes Comment:
harassment order-
Past No Comment:
Juvenile Court Involvement (Related to Child Abuse, Neglect or Dependency):
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page # I
:urrent No Comment:
Past No Comment:
Has a Child In Need of Services (CHINS) petition been filed? No Comment:
Corn me nts:
Child Support Enforcement Orders: None Reported / Comments:
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak#56813 DOS 1018/1978 Page #2
Employment Addendum
Person’s Name (Last, First MI): Record #: Date of Admission:
Stebbins, Richard 158539 02/29/2016
DOB: Gender:
Organization Name/Program Name: Advocates, Inc./ Outpatient 10/08/1978 Male
Employment Addendum
17j Current Employment
Employment Status: Part lime (< 32 hours per week)
Is person served satisfied with job? Is persons served job in jeopardy?
L Not in Labor Force; - Date Last Worked:
If other, please explain
fl Is the person concerned that employment will effect current benefits:
If yes, please exptain
Name of most recent employer:
Reason(s) for Leaving Jobs in Last 5 years: D NA
Medical problems
If other, please explain
Attendance: Normal
Performance: Average
Comments:
Past jobs
Out of work for 2 years due to muscle medical issues
Richard Slebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 1018/1978 Page # 1
Education
Addendum
Person’s Name (Last, First MI): Record It: Date
of Admission:
Stebbins, Richard 158539 02/29)2016
DOB:
Gender:
Organization
Name/Program Name: Advocates,
Inc.! Outpatient 10/08/1978 Male
Education Addendum
Major/Degree(s) Year Completed
1. 1.
2. 2.
3. 3.
Vocational Training: None Reported
VocationaL License(s)/Certification(s) Year Completed
1. 1.
2. 2.
3. 3.
Educational
Interests/Skills:
Is person served satisfied with his/her current educational situation? No
Person’s status in school is in good standing NA
Does the Person want to pursue additional education? Uncertain
Comments:
History of Learning Difficulties: None Reported
Performance
/ Behavioral Problems related to:
H Learning Disability: Type(s):
fl Developmental Disability (DO):
Other/Comments (include sources of information):
Barriers to Learning:
Richard Stebbins Record #158539 ClfentNo #156720 Claimtrak #56813 DOB 1018/1978 Page # I
None Reported
Other/Comments:
Comments:
Springfield Technical Community College- a year and half worth of classes. Stopped because moved.
to far to travel.
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOD 10/8/1978 Page #2
Addictive Behavior and Substance Use History Addendum
Perso&s Name (Last, First MI): Record #: - Date of Admission:
Stebbins, Richard 158539 02/29/2016
DOB: Gender:
Organization Name/Program Name: Advocates, Inc.! Outpatient 10/08/1978 Male
Substance Use / Addictive Behavior History Addendum
Addiction Age of First pate of Last omment Frequency Amount Method g’lethod Other
me
Alcohol 21 last week Denies any 1-3 times in the see side Oral
OUls, has past 30 days
experienced
blackouts- has
been checked
due to memory
problems.
Denies any
drinking to get
rid of hangover,
denies any
drinking while
working.
Maruana 36 Medical No use in the see side Smoke
marijuana past 30 days
Does not use it
anymore- for
muscular
myopaty and
stress.
Toward end gave
him anxiety -
last October
Card has expired
Treatment History
$ervice Dates of Service Reason Name of Provider/ ompleted
Agency
Toxicology Screen Completed: No — If Yes, Results:
Longest period of abstinence:
American Society of Addiction Medicine (ASAM) Degree of Severity at Admission for the Following Dimensions
flNA
Richard Stebbins Record #158539 ClieniNo #156720 Claimlrak #56813 DOS 10/8/1978 Page #1
Dimension
1
Intoxication
/
Biomedical Emotional
/
Readiness to Relapse
/
Recovery
Family
Withdrawal Conditions
/
Behavioral
/ Change Continued
Use
Environment
Functioning
Potential Complications Cognitive
Potential
(Youth
Only)
For
Persons considering
an
Opiate
Treatment
Program
complete this
box
RI
Not
Applicable
If
under
age
iS
dates
of
two
attempts
to quit
prior to
today
Evidence of
tolerance
to
an Opicid:
Multiple
and
daily
self-administration
of
an
Opioid:
Evidence
of two
or
more proofs
of
narcotic
dependence:
Other Comments Regarding
Substance
Use
(Include
SU
by
other
family
members/significant others,
SU
related
legal
problems,
and
stage
of
treatment
information):
Richard Stebbins Record #158539 ClieniNo #156720 Claimtral< #56813 DOB 101811978 Page #2
BSAS
TB
Assessment
Name: Stebbins, Richard
Center:
Date: 02/29/2016
TB
History
lithe answer is yes to any of the following questions, then do a symptom screen.
1. Have you ever had a positive skin test for TB No
Do you have the results written down?
Date Result
2. Have you ever had a positive blood test for TB? No
Date Result
lithe answer is ‘no to all of the above, STOPl
3. Do you have a chest x-ray result written down?
Date
Result: normal abnormal
4. Did you take medication for your positive skin test?
S. Have you ever been sick with TB disease?
If yes, did you take medication for your illness?
TB
Risk
Assessment
lithe answer is ‘yes to any of the following questions, then do a symptom screen.
Risk Factors
1. Have you lived with or spent time with anyone who has been sick with TB in the last 2 years? No
2. Have you ever lived or traveled for more than a month in Asia, Africa, Eastern Europe, Middle
Et, Russia, Central or South America or the
Caribbean?
No
3, Do you have AIDS or HIV infection or other immune-compromised condition? No
4. Do you have (or have you had) other medical conditions such as: No
Diabetes? No
Cancer? No
Kidney Disease? No
Rheumatoid arthritis? No
Stomach or intestinal surger No
TB
Symptom Screening
Symptoms
1. Have you had a prolonged, unexplained cough lasting more than 3 weeks or a recent change in chronic cough? No
2. Have you recently lost weight of 10 pounds or more for no apparent reason? No
3. Do you sweat at night? No
4. Have you felt unusually tired recently? No
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 OOB 10/8/1978 Page #1
Infectious Disease Risk Addendum
Person’s Name (Last, First MI): Record 4*: Date of Admission:
Stebbins, Richard 158539
DOB: Gender;
Organization Name/Program Name: Advocates, Inc.! Outpatient 10/08/1978 Male
(Check all that apply below)
i. what drugs do you usually use? Marijuana,Alcohol
If other, please explain
2. How do you use your drugs? Ora!,Srnoke
If other, please explain
3. If you inject drugs, how often do you use new needles? N/A
4. If you use new needles, where do you get them? N/A
If other, please explain
5. If you use needles, how do you dispose of them? N/A
If other, please explain
6, Do you ever share needles/injection equipment? N/A
7. In the ast five years, about how many people have you had sex with? 0-2
8. How often do you use protecton against infections? Never
9. Have you had sex for money, drugs or something you needed? No
10, Wnen was tie last time you were tested for HIV? Last couple of years. Never
11. Did you receive your results? Yes
12. Would you like more information about HIV where to get tested / treated? No
Richard Stebbins Record #158539 ClientNo #156720 Claimlrak #56813 DOB 10/811978 Page # I
Please check what was provided to Person Served below: Discussion OnIy,HIV Fact Sheet
If other, please explain
Never tested positive for Hep. C- has been tested due to current medical problems.
Other Notes I Recommendations:
— Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOG 10/811978 Page #2
Signature Sheets
Signature Role NameITitIe Degree License Date Signature
MCI Clinician Ushinski, Lukas MSW LJCSW 7/28/2016 Passwurd Authenticated
BI-1 - WISR CLINICAL SLJPERVIOSR
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page # 1
Psychotherapy
Progress
Note
Person’s Name (Last,
First
MI):
II
Record
#:
D.O.B.:
Stebbins,
Richard 158539
10/08/1978
Organization
Name:
Advocates,
Inc.
Modality
Individual
List
Names
of
Person
Person
Present
Present
Explanation:
Others
Present (please
identify
name(s)
and relationship(s)
to
Person):
Initial
assessment
Person’s
report
of
progress
towards goals/objectives
since last session:
New
Issue(s)
Presented
today:
Person’s
Condition
Changes
in
Person’s
Condition
Mood/Affect:
see assessment
Thought
Process/
see
assessment
Orientation:
Behavior/
see
assessment
Functioning:
Medical
Condition: see assessment
Substance
Use:
Li
NA
see assessment
DangerTo:
1J
None
Self:
[El
Others:
OR Check
all
that
apply below and record action taken
in
Therapeutic Interventions section below
-
Comments:
R[chard Stebbins Record #158539 ClientNo #156720 DOB 1018/1978 Page # 1
El
Property:
Therapeutic Interventions
Delivered
in
Session:
Assess
level
of functioningProvide
diagnosis
Person’s
Response to
Intervention/Progress
Toward
Goals
and
Objectives:
Client
cooperative, completed
all
forms
and
answered
all
questions
asked
Plan/Additional Information
(Indicate action
plan
between sessions):Recommendation letter
El
Medicare
“Incident
To”
services
Name
and
credentials
of
supervising professional
on
Site:
Only
(If Applicable):
Next
Appointment: Date
&
Time:
Date
of
“Provider
ilLoc.
Code
I1Prcdr.
Code
Itop
9Total
“Diagnostic
ITime
[lime
ode
Service Number
“Worcester
1116
loam
11am
hour
fiF331Z653
02/29/2016
]3941
Re-Entry
Ushinski, Lukas
BH -
WISR
CLINICAL
SUPERVIOSR
2/29/2016
Passwurd
Authenticated
Signature
Role
MCI
Clinician
Signature Sheets
Namerritle Degree
License
Date
Signature
MSW LICSW
Richard Stebbins Record #158539 ClientNo #156720 DOB 10/8/1978 Page # 2
Person’s Name (Last, First MI): Record #: Date of Admission:
Stebbins, Richard 158539 02/29/2016
DOB: Gender:
Organization Name/Program Name: Advocates, Inc./ 10/08/1978 Male
Outpatient
fl Transition - From (Unit/Program): To:
{) Discharge
Last Contact: Discharge/Transition Date:
2/29/16
Person’s location and contact information post dischargeftransition:
Wdress: El Unknown
176 B South Street Warren MA
Felephone: 4139491925 fl Unknown
f discharged to shelter, document efforts to prevent:
NA
Status at Last Contact:
Client on probation through Worcester Superior Court Probation Department
Client is on waiting list for therapist and is currently being seen by doctor for psychiatric medications
Summary of Services/Treatment Provided (consider vocational, educational, financial, legal, medical, behavioral and risk status):
Client seen for evaluation only
)utcomes (Include qualitative and quantitative informabon regarding progress/gains achieved, rengths, abilities and
preferences. Specify any standardized measures used):
Health and Safety Concerns (include behavioral, medical and/or substance use issues): U Not applicable
Client has multiple suicide attempts- most recent one in January
Status Towards Meeting Goals:
Dverall Progress In Treatment:
Diagnosis At Intake
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 D08 10/8/1978 Page # 1
[primary Diagnosis IlDiagnosis Type Code/GAF [Narrative Description
Yes DSM-5 (lCD-b) F33.1 Major depressive disorder,
Recurrent episode, Moderate,
No DSM-5 (lCD-to) 765.3 Problems related to other legal
circumstances,
Lowest GAF in Past Year(If Known):
Diagnosis At Transition/Discharge
:Primary Diagnosis IDiagnosis Type Code! GAF Narrative Description
Yes DSM-5 (lCD-b) F33.t Major depressive disorder,
Recurrent episode, Moderate,
No DSM-5 (lCD-b) 765.3 Problems related to other legal
circumstances,
Highest GAF in Past Yearçlf Known):
Reason for Discharge or Transition:
Other
If other, please explain
Client is on waiting list for therapist
Currently has doctor to prescribe psychiatric medications however is not currently taking them.
Lf involuntary/administratively discharged, summary of action taken: Not applicable
erson Served notified of appeal process (explain)
Person’s Response to Treatment and Transition! Discharge:
Medications as Reported by Person at time of Discharge/Transition:
J None Reported
Referred To (Agency/Program Name, Location, and Contact For (describe services/supports, rationale, list bate(s)/Time
Information): dates/times of appointments if known): (s) of Appts. If
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page #2
I Known:
L_____________
ftercare Options (Include information on symptoms person should watch for, options available if these symptoms recur or additional service
needed, and/or follow-up plans):
Client is aware of how to contact emergency services should emergency arise.
Also see recommendation letter
Was person provided copy of Transition/Discharge Plan? No Person did not receive copy
If no, please explain:
Signature Sheets
Signature Role Namelfltle Degree License Date Signature
MCI Clinician Ushinski, Lukas MSW LICSW 7/28/2016 Password Authenticated
BR - WISR CLINICAL SUPERVIOSR
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page #3
Individualized Action Plan
‘erson’s Name (Last, First MI): Record #:
Stebbins, Richard 158539
DOB: Gender:
Organization Name/Program Name: Advocates, Inc./ Outpatient 10/08/1978 Male
Date of Admission: LI Annual lAP-Date: fl Revised lAP-Date:
02)29/20 16
This Section Mandatory For Outpatient Substance Use Counseling Only(Check Here if Not Applic& Piifl
Medications as Reported Dy the Person Served on Date of lAP Development -
J None Reported
Medication Name Dose Plans for Change - Including Prescribed by
Rate of Detox
Dther Agencies/Community Supports and Resources Supporting Individualized Action Plan:
[El None Reported H No Change
Transitionltevel of Care Change/After careIDischarge Plan: [E No Change
DAnticiPated Date:
Agency Name: Contact and Title
:riteria - How will the provider/individual/parent guardian know that level of care change is warranted? (Check All that Apply):
fl Reduction in symptoms as evidenced by:
Services Currently
Provided
Release Signed
H Attainnent of higher level of functioning as evidenced by:
LI Treatment is no longer medically necessary as evidenced by:
LI Other:
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOG 10/S/I 978 Page # I
Plan Completed by (Name, Title, Program):
Ushinski, Lukas, BH - WISR CLINICAL SUPERVIOSR
Was the person served provided copy of the lAP? No Reason;
Seen for evaluation only
Signature Sheets
Signature Role Name/Title Degree License Date Signature
MCI Clinician Ushinski, Lukas MSW LICSW 7/28/2016
Password
Authenticaind
81-I - WISR CLINICAL SUPERVIOSR
Richard Stebbins Record #158539 ClientNo #156720 Clairutrak #56813 006 10/8/1978 Page #2
Adult Comprehensive Assessment
Person’s Name (Last, First MI): Record #: Date of Admission:
Stebbins, Richard 158539 02/29/2016
DOB: Sender:
Organization Namef Program Name: Advocates, Inc./ Outpatient 10/08/1978 Male
Comprehensive Assessment Date: 02/29/2016
Presenting Concerns (In Person’s Served/Family’s Own Words)
Referral Source:
Worcester Superior Court Probation Department
Reason for Referral:
Client has condition of probation to complete a mental health evaluation
What Occurred to Cause the Person to Seek Services Now (Note Precipitating Event, Symptoms, Behavioral and Functioning Needs):
Probation began: February 5, 2016
Probation ends: February 2017
Offense: forgery
- Living Situation
What is the persons current living situation? (check one)
Person’s Home:
Residential Care/Treatment Facility:
Other:
apartment- living with wife
t Risk of Losing Current Housing No Satisfied with Current Living Situation Yes
Comments (Include environmental surroundings and neighborhood description):
Family History
Family History and Relationship, Parental/ Familial Caretaker Obligations:
Parents: Client age 21 when parents divorced - just didn’t get along.
Mother in Springfield, MA- talk to her couple times a week, see her every few weeks. Described as good’
Father in West Warren, MA- talk to him couple times a week, see him couple times a week, Described as “good”
Younger brother and sister- brother lives in Munson, MA and every couple weeks talks to week. Sister lives in Springfield with mom,
Samantha 19- haven’t seen her since 2002. Mother wanted to raise child on own and then didn’t have to pay child support and was already
having hard time seeing her,
Nathan 16- Never seen him. Didn’t get a long with mother- just a fling. Does not pay child support.
Dietrich born 2003 - haven’t seen since 2004. Child with ex-wife and she ended up marrying a friend of his and he ended adopting him. No
child support.
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page # 1
First wife- marrIed 4 years- reason for divorce - didn’t get along anymore and went separate ways. 2000
2011- current marriage. No children reported.
Married
Pertinent Family Medical, MH and SU History:
Denies any substance abuse hx in family.
Mother- depressions. Doesn’t know if she is on medications
Developmental History and Status:
Putnam High School in Springfield, MA graduated.
Denies any special education classes or dx with a learning disorder.
Denies any AD/HD dx.
Ritalin- 2nd or 3rd less than 6 months. Didn’t help.
Social
Support
Friendship/Social/Peer Support Relationships, Pets,Community Supports/Self Help Groups: (M, NA, SMART, NAMI, Peer Support,
etc.):
8 friends - talk to them or see them every couple of weeks.
Never attended M/NA
Religion/Spirituality and Cultural/Ethnic Information:
Catholic
Does not currently practice
Caucasian
Legal
Status and
Legal
Involvement and History
Does Person Served have a Legal Guardian, Rep Payee or Conservatorship? No
If yes, complete and attach the Legal Status Addendum
Is there a need for a Legal Guardian, Rep Payee or Conservatorship? No Explain:
Does the person have a history of, or current involvement with the legal system (i.e., legal charges)? Yes
If yes, complete and attach the legal Involvement and History Addendum
Education
Highest Level of Education Achieved:
HS Grad
Highest Grade Completed: COL - Some college credit/no degree
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOS 10/8/1978 Page #2
Person’s Preferred Learning Style(s):
Learn by doing,Verbal,Visual,Written,Auditory
Currently Enrolled in Educational Program? No
Is person interested in further education or assistance in education? Yes
If the answer to either of the above questions is yes, complete and attach the Education Addendum.
Employment and Meaningful Activities
Employment Status/Interests:
fl Never Worked Currently Employed? Yes If yes, length of employment:
Advantage Sales and Marketing- part time currently
(If not currently employed) — Person served wants to work? / Comments:
Does the person want help to find employment? Yes If yes, complete Employment Addendum
Comments:
Meaningful Activities (Community Involvement, Volunteer Activities, Leisure/Recreation, Other Interests):
Additional Information:
hiking, fishing, bike riding and gym, reading
Income/Financial Support
How does the person describe her/his current financial situation?
Occasional struggle with finances
Comments:
Sources Of Financial Assistance Amount
biIit No
FoodStamps No
SSDI No
LS51 No
Contributions from family or friends No
Child Support No
erans Benefits No
Richard Slebbins Record #158539 ClieniNo #156720 Claimtrak #56813 006 10/8/1978 Page #3
TAFDC No
EAEDC No —]
Other
Other
Military Service
None Reported - If None reported, skip to the Substance Use / Addictive Behavior History Section
Military Experience: Date of Discharge:
None
Type of Discharge
Reason:
Is a complete Military Service Asssessment needed? No If yes, complete and attach Military Service Addendum
Addictive Behavior and Substance Abuse History
Does person report a history of, or current substance use or other addictive behavior concerns (i.e., alcohol, tobacco, gambling, food)?
Yes
If yes, complete and attach Addictive Behavior History/SA Addendum.
Mental Health and Addiction Treatment History
Type of Service ervice Dates of Service Reason Name of Inpatient! ompleted
Provider/ utpatient
4gency I
Efficacy of past and current treatment:
Psychiatric History (including past diagnoses):
5 psychiatric Hospitalizations
1- 2005 Springfield Baystate medical Center- drank a gallon of vodka- 2 weeks in psych ward because suicide attempt. Had caught wife
cheating on him. Prozac and
2-2005 Depakote Carbitral prescribed. Less Uien 6 months- suicide attempt again, pills and alcohol. Sister had brought him to hospital - 2
week stay.
3- last year October Caught wife cheating on him. Cut self on left forearm, Wife had called ambulance. She had text him and he said
goodbye so she called police. Mary Lane, Ware Hospital- there for 3 days. Was prescribed medications Lithium was one of them - maybe a
few others. took them while at hospital but then stopped after.
4- December- Wing Memorial in Palmer - right before Christmas- taken a bunch of pills, Ativan. Was prescribed to him. Wife noticed
breathing was off and something off. 4-5 days in hospital. Cave irregular heartbeat. Day and half in psych ward then let go. The stress and
anxiety of wife cheating.
Richard Stebbins Record #158539 ClienINo #156720 Claimtrak #56813 DOB 10/611978 Page #4
5-January another week In psych ward. Wing Memorial In Palmer. Drank rat poison- wife wanted to talk. So In-between she called the ps
and the cops took him to emergency room.
Is not on medication now.
Memory problems.
Randomly maybe 3 or 4 times.
Not helpful.
BHN- was seeing
Went for months- Every other week
never weekly.
Denies any outpatient substance abuse counseling.
Denies any detox admissions
Couples counseling- she was supposed to schedule something.
Anxiety- October 2015 started last year.
Suicidal thoughts as a teenager.
Griswold Center- Palmer- prescriber and therapist.
still setting up date for therapist.
Source(s) of Information:
Person served
If other, p!ease explain
Physical Health
ame and 5peciaity Address ffice Phone !flx pate of Last Exam
redentials Li H H
Physical Health Summary OR U Refer to Attached Physical Health Assessment
Bureau of Substance Abuse Services (BSAS) Programs must complete the MSDP Infectious Disease Risk
Addendum and the BSAS TB Assessment
Is this person involved in a BSAS Program? Yes
If yes, complete and attach the Infectious Disease Risk Assessment and the TB Intake Form
Allergies:
Food:
No Known Allergies
Medication:
No Known Allergies
Environmental:
No Known Allergies
Richard Stebbins Record #158539 ClientNo #156720 claimtrak #56813 008 10/8/1 978 Page #5
Physical Health Summary: (Include health history, chronic conditions, significant dental history, and current physical complaints that may
interfere with the person’s served functioning.)
Denies any T8I where lost consciousness
Denies any seizure disorders
Denies any heart problems- irregular heartbeat caused by Ativan
Sexual History/Concerns:
Pain Screening:
Does the person experience pain currently? Yes
Has the person experienced pain in the past few weeks? Yes
Describe the type, frequency, duration, intensity, identified cause, any limitations to functioning and what helps relieve the pain:
Muscle myapathy
missed some appointments from being in hospital.
Multiple times a day.
Nutritional Screening: (check all that are reported)
Special Diet? (e.g. diabetic, celiac)
Additional Special Diet information:
Follows Special Diet?
Beliefs, perceptions, attitude, behaviors regarding food:
Physical Health Summary and Recommendations:
If person has not had physical exam in past year, or if person has reported pain without a determined cause, or if person has reported eating
disordered behaviors that are not being medically followed:
Reason person declined exam:
Medication Summary
Medication Information (Include All Non-Psych Meds/Prescription/OTC/Herbal)
L] None Reported
Medication Information and history of adverse reactions: (Include what medications work well and have worked well previously, any
adverse side effects, why person doesn’t take meds as prescribed and/or which one(s) the person would like to avoid taking in the future):
Richard Stebbins Record #158539 ClientNo #156720 Clairntrak #56813 DOS 10/811978 Page #6
Does not know if has any adverse reactions to medications.
Advanced Directive:
Does the person have advanced directives established No
If yes, what type?
If other, please explain
If no, does the person wish to develop them at this time? No I If yes, follow agency’s procedure for completion
Trauma History
Does person report a history of trauma? No
Does person report history/current family/significant other, household, and/or environmental violence, abuse or neglect or exploitation?
No
If the answer to either of the above questions is yes, complete and attach the Trauma History Addendum.
Mental Status Exam — (WNL = Within Normal Limits) (**) — If Checked, Risk Assessment is Required
Appearance/Clothing: WNL
Eye Contact WNL
Build WNL
Posture WNL
Body Movement: WNL
Behavior: Cooperative
Speech: Clear
Emotional State-Mood: (in
person’s words): WNL
Emotional State-Affect: WNL
Facial Expression: WNL
Perception WNL
Hallucinations -
Richard Stebbins Record #158539 ClientNo #156720 Clairntrak #56813 DOB 10/8/1978 Page #7
Thought Content: WNL
Delusions - None reported
Other Content -
Thought Process WNL
Intellectual Functioning WNL
Intelligence Estimate - Average
Orientation: WNL [Disoriented to:
Memory: ]WNL mpaired:
Insight: WNL
Judgment: WNL Impaired Ability to Make Reasonable
Decisions:
Past Attempts to Harm Self Self**
or Others:
If other, please explain
see mental health section
5 reported suicide attempts
Self Abuse Thoughts: None reported
If other, please explain
Suicidal Thoughts: None reported
Aggressive Thoughts: None reported
Comments:
r Person’s Served Strengths/Abilities/ Resiliency
(Skills, talents, interests, aspirations, protective factors)
Personal Qualities: (Examples: open, friendly, likeable, friendly
engaging, motivated, loyal, resourceful, caring,
thoughtful)
Living Situation: (Examples: has maintained long-
term stable housing, gets along with living
companions) -
FinancialfEniployment/Education: (Examples: I
graduated F-IS, attended college, currently working, hx
graduated F-IS, some college
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page # 8
of working, multiple work skills)
Health: (Examples: consistent good health, exercises actively addressing health issues
regularly, self cares for health issues as directed by
physician, eats nutritional foods)
Leisure/Recreational/Community Involvement: hiking, reading, bike riding, gym
(Examples: plays a sport, belongs to social group,
attends gym, volunteers for Red Cross)
Natural Supports: (Examples: Family members,
clergy, close friends, neighbors, advisors)
I Spirituaiity/Culture/Religion: (Examples: enjoys
religious services, participates in cultural events,
meets regularly with rabbi)
Assessed Needs
Li If checked, agency’s functional assessment should be completed
turrent Need Group ‘turrent Need Area !lDesires Change YIN
Mental Health/Illness Management-Behavior Depression/Sadness Yes
Management
Evidenced By: hx of S suicide attempts- most recent December 2015 and January 2016, hx of psych medications, hx of psych hospitalizations
Legal Legal Issues Yes
Evidenced By: on probation
Additional Addendums
Select Additional Addendums Needed to be Attached:
Addictive Behavior and Substance Use History Addendum,Legal Involvement and History Addendum
Clinical Formulation - Interpretive Summary
This Clinical Formulation is Based Upon Information Provided By (Check All that apply):
Person served
If otner, please explain
Interpretive Summary: What in your clinical judgment are the need areas, the factors that led to the needs, and your plan to address them?
Limits of confidentiality reviewed. Release of information signed.
See recommendation letter in chart.
Meets DSM 5 criteria for Major Depressive Disorder, Recurrent Episode Moderate
Further Evaluations Needed:
Medical, Psychiatric
If other, please explain
Client has medical disorder and is actively addressing it.
Client has psychiatric appointment set up in March to see medication prescriber. Also is waiting to be assigned a therapist
Richard Stebbins Record #158539 ClieniNo #156720 Claimtrak #56813 00810/8/1978 Page #9
Patient Stress Questionnaire
Was Outcomes tool administered? Yes if Yes, specify:
Diagnosis:
Primary Diagnosis [Diagnosis Type [ode/GAF [[Narrative Description
Yes DSM-5 (lCD-b) F33.1 Major depressive disorder,
Recurrent episode, Moderate,
No DSM-5 (lCD-b) Z65.3 Problems related to other legal
circumstances,
Ranking urrent Need Group Current Need Area Active/Person Declined!
I DeferredlReferred Out
1 Mental Health/Illness Management- Depression/Sadness
Behavior Management
Referred Out
Rationale: Assessed need to be
get appointment by April 1
addressed by therapist (currently on wait list to be seen) Client is come back to meet this clinician if unable to
2 Legal Legal Issues Referred Out
Rationale: Assessed need to be addressed by probation officer
Person’s Service Preferences, Level of Care/Indicated Services Recommendation:
Outpatient Treatment
Person Served/Guardian/Family Response To Recommendations:
Next Appointment: Date & Time:
Date of Service Provider Loc. Code Prcdr. Mod 1 Mod 2 Mod 3 Mod 4 Start Time IStop Time Total Diagnostic
Number Code Time Code
02/29/2016 3941 Norcester 16 10am 11am 1 hour F33.1,
Re-Entry 65.3
Prioritized Assessed Needs:
(If declined/deferred/referred out, please provide rationale)
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page# 10
Legal Involvement and History Addendum
Person’s Name (Last, First MI): Record #: Date of Admission:
Stebbins, Richard 158539 02/29/2016
DOB: Gender:
Organization Name/Program Name: Advocates, Inc.! Outpatient 10/08/1978 Male
Legal Involvement and History Addendum
Legal Charges Designation tatus utcome Begin Date End Date 1 Incident
I Description
Other Adult Open past adult charges malicious damage
to motor vehicle-
she hit client and
did not have
insurance. Siter
and cousin who are
police officer.
Forgery - court
order placed in
mailbox. Access to
Clis and to see that
she was driving
without insurance
that day.
Did not serve any
time.
Name and Phone Number of Court (if applicable):
Worcester Superior Court Probation Department- Anthony Gigliotti
Relationship Sub-Relationship IlName ffice Phone ell Phone
Mama and Phone Number of Probation! Parole Officer (if applicable):
Domestic Relations Court Involvement (i.e., Custody, Protective Services, Restraining Order):
Current Yes Comment:
harassment order-
Past No Comment:
Juvenile Court Involvement (Related to Child Abuse, Neglect or Dependency):
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page # I
:urrent No Comment:
Past No Comment:
Has a Child In Need of Services (CHINS) petition been filed? No Comment:
Corn me nts:
Child Support Enforcement Orders: None Reported / Comments:
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak#56813 DOS 1018/1978 Page #2
Employment Addendum
Person’s Name (Last, First MI): Record #: Date of Admission:
Stebbins, Richard 158539 02/29/2016
DOB: Gender:
Organization Name/Program Name: Advocates, Inc./ Outpatient 10/08/1978 Male
Employment Addendum
17j Current Employment
Employment Status: Part lime (< 32 hours per week)
Is person served satisfied with job? Is persons served job in jeopardy?
L Not in Labor Force; - Date Last Worked:
If other, please explain
fl Is the person concerned that employment will effect current benefits:
If yes, please exptain
Name of most recent employer:
Reason(s) for Leaving Jobs in Last 5 years: D NA
Medical problems
If other, please explain
Attendance: Normal
Performance: Average
Comments:
Past jobs
Out of work for 2 years due to muscle medical issues
Richard Slebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 1018/1978 Page # 1
Education
Addendum
Person’s Name (Last, First MI): Record It: Date
of Admission:
Stebbins, Richard 158539 02/29)2016
DOB:
Gender:
Organization
Name/Program Name: Advocates,
Inc.! Outpatient 10/08/1978 Male
Education Addendum
Major/Degree(s) Year Completed
1. 1.
2. 2.
3. 3.
Vocational Training: None Reported
VocationaL License(s)/Certification(s) Year Completed
1. 1.
2. 2.
3. 3.
Educational
Interests/Skills:
Is person served satisfied with his/her current educational situation? No
Person’s status in school is in good standing NA
Does the Person want to pursue additional education? Uncertain
Comments:
History of Learning Difficulties: None Reported
Performance
/ Behavioral Problems related to:
H Learning Disability: Type(s):
fl Developmental Disability (DO):
Other/Comments (include sources of information):
Barriers to Learning:
Richard Stebbins Record #158539 ClfentNo #156720 Claimtrak #56813 DOB 1018/1978 Page # I
None Reported
Other/Comments:
Comments:
Springfield Technical Community College- a year and half worth of classes. Stopped because moved.
to far to travel.
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOD 10/8/1978 Page #2
Addictive Behavior and Substance Use History Addendum
Perso&s Name (Last, First MI): Record #: - Date of Admission:
Stebbins, Richard 158539 02/29/2016
DOB: Gender:
Organization Name/Program Name: Advocates, Inc.! Outpatient 10/08/1978 Male
Substance Use / Addictive Behavior History Addendum
Addiction Age of First pate of Last omment Frequency Amount Method g’lethod Other
me
Alcohol 21 last week Denies any 1-3 times in the see side Oral
OUls, has past 30 days
experienced
blackouts- has
been checked
due to memory
problems.
Denies any
drinking to get
rid of hangover,
denies any
drinking while
working.
Maruana 36 Medical No use in the see side Smoke
marijuana past 30 days
Does not use it
anymore- for
muscular
myopaty and
stress.
Toward end gave
him anxiety -
last October
Card has expired
Treatment History
$ervice Dates of Service Reason Name of Provider/ ompleted
Agency
Toxicology Screen Completed: No — If Yes, Results:
Longest period of abstinence:
American Society of Addiction Medicine (ASAM) Degree of Severity at Admission for the Following Dimensions
flNA
Richard Stebbins Record #158539 ClieniNo #156720 Claimlrak #56813 DOS 10/8/1978 Page #1
Dimension
1
Intoxication
/
Biomedical Emotional
/
Readiness to Relapse
/
Recovery
Family
Withdrawal Conditions
/
Behavioral
/ Change Continued
Use
Environment
Functioning
Potential Complications Cognitive
Potential
(Youth
Only)
For
Persons considering
an
Opiate
Treatment
Program
complete this
box
RI
Not
Applicable
If
under
age
iS
dates
of
two
attempts
to quit
prior to
today
Evidence of
tolerance
to
an Opicid:
Multiple
and
daily
self-administration
of
an
Opioid:
Evidence
of two
or
more proofs
of
narcotic
dependence:
Other Comments Regarding
Substance
Use
(Include
SU
by
other
family
members/significant others,
SU
related
legal
problems,
and
stage
of
treatment
information):
Richard Stebbins Record #158539 ClieniNo #156720 Claimtral< #56813 DOB 101811978 Page #2
BSAS
TB
Assessment
Name: Stebbins, Richard
Center:
Date: 02/29/2016
TB
History
lithe answer is yes to any of the following questions, then do a symptom screen.
1. Have you ever had a positive skin test for TB No
Do you have the results written down?
Date Result
2. Have you ever had a positive blood test for TB? No
Date Result
lithe answer is ‘no to all of the above, STOPl
3. Do you have a chest x-ray result written down?
Date
Result: normal abnormal
4. Did you take medication for your positive skin test?
S. Have you ever been sick with TB disease?
If yes, did you take medication for your illness?
TB
Risk
Assessment
lithe answer is ‘yes to any of the following questions, then do a symptom screen.
Risk Factors
1. Have you lived with or spent time with anyone who has been sick with TB in the last 2 years? No
2. Have you ever lived or traveled for more than a month in Asia, Africa, Eastern Europe, Middle
Et, Russia, Central or South America or the
Caribbean?
No
3, Do you have AIDS or HIV infection or other immune-compromised condition? No
4. Do you have (or have you had) other medical conditions such as: No
Diabetes? No
Cancer? No
Kidney Disease? No
Rheumatoid arthritis? No
Stomach or intestinal surger No
TB
Symptom Screening
Symptoms
1. Have you had a prolonged, unexplained cough lasting more than 3 weeks or a recent change in chronic cough? No
2. Have you recently lost weight of 10 pounds or more for no apparent reason? No
3. Do you sweat at night? No
4. Have you felt unusually tired recently? No
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 OOB 10/8/1978 Page #1
Infectious Disease Risk Addendum
Person’s Name (Last, First MI): Record 4*: Date of Admission:
Stebbins, Richard 158539
DOB: Gender;
Organization Name/Program Name: Advocates, Inc.! Outpatient 10/08/1978 Male
(Check all that apply below)
i. what drugs do you usually use? Marijuana,Alcohol
If other, please explain
2. How do you use your drugs? Ora!,Srnoke
If other, please explain
3. If you inject drugs, how often do you use new needles? N/A
4. If you use new needles, where do you get them? N/A
If other, please explain
5. If you use needles, how do you dispose of them? N/A
If other, please explain
6, Do you ever share needles/injection equipment? N/A
7. In the ast five years, about how many people have you had sex with? 0-2
8. How often do you use protecton against infections? Never
9. Have you had sex for money, drugs or something you needed? No
10, Wnen was tie last time you were tested for HIV? Last couple of years. Never
11. Did you receive your results? Yes
12. Would you like more information about HIV where to get tested / treated? No
Richard Stebbins Record #158539 ClientNo #156720 Claimlrak #56813 DOB 10/811978 Page # I
Please check what was provided to Person Served below: Discussion OnIy,HIV Fact Sheet
If other, please explain
Never tested positive for Hep. C- has been tested due to current medical problems.
Other Notes I Recommendations:
— Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOG 10/811978 Page #2
Signature Sheets
Signature Role NameITitIe Degree License Date Signature
MCI Clinician Ushinski, Lukas MSW LJCSW 7/28/2016 Passwurd Authenticated
BI-1 - WISR CLINICAL SLJPERVIOSR
Richard Stebbins Record #158539 ClientNo #156720 Claimtrak #56813 DOB 10/8/1978 Page # 1
Psychotherapy
Progress
Note
Person’s Name (Last,
First
MI):
II
Record
#:
D.O.B.:
Stebbins,
Richard 158539
10/08/1978
Organization
Name:
Advocates,
Inc.
Modality
Individual
List
Names
of
Person
Person
Present
Present
Explanation:
Others
Present (please
identify
name(s)
and relationship(s)
to
Person):
Initial
assessment
Person’s
report
of
progress
towards goals/objectives
since last session:
New
Issue(s)
Presented
today:
Person’s
Condition
Changes
in
Person’s
Condition
Mood/Affect:
see assessment
Thought
Process/
see
assessment
Orientation:
Behavior/
see
assessment
Functioning:
Medical
Condition: see assessment
Substance
Use:
Li
NA
see assessment
DangerTo:
1J
None
Self:
[El
Others:
OR Check
all
that
apply below and record action taken
in
Therapeutic Interventions section below
-
Comments:
R[chard Stebbins Record #158539 ClientNo #156720 DOB 1018/1978 Page # 1
El
Property:
Therapeutic Interventions
Delivered
in
Session:
Assess
level
of functioningProvide
diagnosis
Person’s
Response to
Intervention/Progress
Toward
Goals
and
Objectives:
Client
cooperative, completed
all
forms
and
answered
all
questions
asked
Plan/Additional Information
(Indicate action
plan
between sessions):Recommendation letter
El
Medicare
“Incident
To”
services
Name
and
credentials
of
supervising professional
on
Site:
Only
(If Applicable):
Next
Appointment: Date
&
Time:
Date
of
“Provider
ilLoc.
Code
I1Prcdr.
Code
Itop
9Total
“Diagnostic
ITime
[lime
ode
Service Number
“Worcester
1116
loam
11am
hour
fiF331Z653
02/29/2016
]3941
Re-Entry
Ushinski, Lukas
BH -
WISR
CLINICAL
SUPERVIOSR
2/29/2016
Passwurd
Authenticated
Signature
Role
MCI
Clinician
Signature Sheets
Namerritle Degree
License
Date
Signature
MSW LICSW
Richard Stebbins Record #158539 ClientNo #156720 DOB 10/8/1978 Page # 2
March
I don't know why there's not more information here my marriage with Laura dissolved I was March it was pretty rough I was a disaster after losing that court case since I'm sure she couldn't deal with my nonsense anymore and I didn't even know what my nonsense was all about.
Our breakup was terrible she wanted to keep Harley and there was no way in hell I was going to let that happen. When I was in the Psych Ward she knew my father said that we could not have a dog his rules said no. And she talked me into agreeing to get a puppy while I was in the psych ward anyway and showed me a video which I'm going to place online and add to this
Saturday April 16th did the Westfield Wildwater Canoe races this year I erased with my brother we came in second place and a bunch of his friends raced as well
May 22nd we went to the coolest World War Two reenactment event I've ever seen in my entire life. I took Dominick one of my brother and his kids.
Sept 2015, I had developed breast tissue and had to have it removed. It was quite embarrassing from all the drugs that those doctors were pumping me up Misdiagnosis
Dominic played soccer this year, I think that was the last year that he played as well.
July 3rd my mother sent me a goofy picture of Harley jumping on dominic's dog's Bugsy's back
I took Dominic fishing in the Chicopee River underneath the bridge between Wilbraham and Ludlow. I have fond memories of going there as a child we caught a pickerel that had a wound on its side. i'll have to tell that story later.
September 2016 Tammy's sister Allison reached out to me September 4th I hadn't talked to her in 25 years since before her sister died. I tried to tell her everything I could remember but I was really sick at the time and when I went back and read my messages I realized that I told her some things that were wrong. The police had twisted some of my words and I don't know why I told her what they wanted me to say.
Took Dominic over my dad's September 5th for a family get together even though I had moved out at the beginning of the year I still kept trying to work on everyone's relationship
met Beth on plenty of fish a dating site and we went to see suicide squad at the Hadley movies theater at the Hampshire mall and then got chicken wings and talked at Arizona pizza after for a few couple hours. I told Beth My life story, the issues I had with my children’s mothers, the issues I had in the Coast Guard, my suicide attempts, and my troubles with the courts.
She told me all about the abuse her son suffered in a group home near fall, How the state of Massachusetts place their son as far away as possible, and did nothing to help him when he was assaulted, she only discovered her son was injured when her and her husband daughter arrived for a surprise visit around Halloween in 2015 and discovered that he was bleeding from his ear and they called 911 and he was brought to the emergency room, It was discovered that someone slapped him across the side of the head and blew out his eardrum. The company that he was staying with, tried to cover it up and bleach the room before police rrived. Beth tried to take her son home after that to care for him, but he had suffered too much PTSD, and she was forced to allow the state to take him and place him in the psych ward in New Hampshire, two hours away,And that ruined her marriage with her husband, and since my marriage was Destroyed for my court issues as well, that’s how we were able to meet. Both of us were screwed by the state and it ruined both of our marriages.
After that, the next day, we met up and went to the bridge of flowers in Shelburne Falls mass and took a ride, hoping to see a sunset overlooking north Adams, but we didn’t have any luck.
After that, we became inseparable we hung around all the time I believe we went to visit her son in the psych ward the very first week we met. I think it was just three days later or four days later.
- New Hampshire psych ward:
Beth’s son was placed 2 hours away even though there were closer options. You explained how doctors and state workers lied, sedated him, and even threatened to accuse Beth of abandonment to coerce her into unsafe placements .
Nice I’m glad you caught that cause I’m gonna talk about stuff like this. You put in parentheses Beth made me drive. I wrote that when I was sick, I didn’t feel that way when I was healthy. I used to love driving. We used to talk all the time. When I was in the passenger seat, I had tend to see to play on my phone and stare out the window and not pay attention. But when I was driving, I would pay more attention and be in the moment.
Link to Bay State Mental Health Records 2015-2016
Medications for the year.
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