In your professional capacity as a substance abuse counselor, you are not permitted to give diagnoses for mental disorders other than those related to substance abuse. However, you will likely be exposed to clients with mental health disorders in the assessment or treatment process. The competent substance abuse evaluator will be able to identify clients who present mental health disorders and make the appropriate referrals. Providing appropriate referrals for clients is common in the substance abuse field.

In M1: Assignment 3, you developed a case history for a person with an addiction. In this assignment, you will develop a case history and include one mental disorder. The inclusion of a mental disorder in your case study will aid in the examination of co-occurring disorders. You will then present your diagnosis and referrals.

This assignment has two parts. Complete both parts.

Part I

Create a case history for a person with an addiction and a mental disorder. Do not include identifying information. Include the following elements in your case history:

• Demographicsincluding age, gender, ethnicity, socioeconomic status, marital status, number and ages of children, living arrangements, and religion if applicable
• Presenting problem
• Previous psychiatric treatment of patient
• Previous chemical treatment of patient
• Chemical history
• Medical historyincluding disabilities if applicable
• Work and education history
• Legal or financial concerns
• Family background
• Concerned person involvement
• Referral source

Part II

Analyze the case history and present your diagnosis as related to substance use disorders. Include the following in your diagnosis:

• Summarize key case study elements you would use to formulate a diagnosis and guide your treatment plan.
• Identify at least two assessment tools that you would use to formulate a diagnosis. Justify why you have selected these tools.
• State your diagnosis related to substance use disorders. Justify your reasons for your diagnosis.
• Identify other concerns and offer recommendations and referral opportunities. Justify your reasons and explanations.