provide an outline in bullet format no more than 200 words for this text: 
Client's Name: Lisa Johnson
Date of Evaluation: October 2nd, 2024
Presenting Scenario
Lisa Johnson is a 28-year-old African American female who has been using heroin for the past six years. Initially, she snorted the drug, but four years ago she began intravenous use. Lisa injects heroin 4–6 times daily. She arrived at the Serenity Recovery Center voluntarily after experiencing an overdose and a subsequent hospitalization.
Personal Status
Lisa is the youngest of four siblings, with two older brothers and an older sister. Born and raised in Detroit, Michigan, she moved to Chicago at the age of 22 seeking employment opportunities. Lisa is single and has a four-year-old son who currently resides with her mother. Her relationship with her family is strained due to her substance use, but she maintains sporadic contact with her mother and son. Lisa reports limited social support and describes feelings of isolation.
Drug History and Current Pattern of Use
Lisa began experimenting with substances at the age of 14, starting with alcohol and marijuana. By 18, she was using cocaine occasionally. At 22, after moving to Chicago, she was introduced to prescription opioids following a workplace injury. When prescriptions became difficult to obtain, she transitioned to heroin use at 24. Initially snorting heroin, she shifted to intravenous use two years later. Lisa currently injects heroin multiple times daily to avoid withdrawal symptoms, which include severe muscle aches, nausea, and anxiety. She acknowledges the pervasive impact of her substance use on various aspects of her life.
Substance Abuse Treatment History
Lisa has attempted treatment on two prior occasions. Three years ago, she completed a 28-day inpatient program but relapsed within two months. Last year, she enrolled in an outpatient methadone maintenance program but discontinued after six weeks due to transportation issues and lack of support. She has not engaged in any formal treatment since then. Lisa expresses a desire for sustained recovery but cites significant challenges in maintaining abstinence.
Medical History and Current Status
Lisa reports an unremarkable developmental history, reaching milestones at appropriate ages. She denies any significant childhood illnesses. At 22, she sustained a lower back injury while working in a warehouse, which initiated her use of prescription opioids. Lisa reports chronic back pain, which she manages with heroin use. She has not sought medical evaluation for her pain in over two years. Lisa is not currently taking any prescribed medications. She has not been tested for infectious diseases despite her intravenous drug use.
Mental Health History
Lisa reports a history of depressive symptoms, including persistent sadness, feelings of hopelessness, and insomnia. These symptoms have been present intermittently since adolescence but have intensified in recent years. She has never received a formal mental health diagnosis or treatment. Lisa denies any history of suicidal ideation or attempts. She acknowledges increased anxiety and occasional panic attacks, particularly when experiencing withdrawal symptoms. Lisa exhibits signs of low self-esteem and expresses guilt over her inability to care for her son.
Family History and Current Relationships
Lisa grew up in a single-parent household after her father left when she was eight years old. Her mother worked multiple jobs to support the family. Substance use is prevalent in her family; her oldest brother struggles with alcohol dependence, and her sister has a history of cocaine use. Lisa's mother provides care for Lisa's son but expresses frustration with Lisa's inability to overcome her addiction. Family interactions are often tense, and Lisa feels judged and unsupported. She has minimal contact with her siblings.
Positive Support Systems
Lisa identifies her mother as a potential support, although their relationship is strained. She expresses a desire to rebuild trust with her family. Lisa has a friend from work, Maria, who is drug-free and has offered support. Maria has encouraged Lisa to seek treatment and has accompanied her to the recovery center. Lisa has limited connections to community resources but is open to exploring support groups.
Legal History
Lisa has been arrested twice for possession of controlled substances. Both incidents resulted in probation and mandatory drug counseling, which she did not complete. She is currently on probation and faces potential incarceration if she fails to comply with treatment requirements. Lisa expresses concern about legal repercussions and the impact on her ability to regain custody of her son.
Education
Lisa completed high school and graduated with honors. She attended community college for one year, studying business administration, but dropped out due to financial difficulties. Lisa demonstrates above-average intelligence and possesses strong verbal skills. She expresses interest in returning to school in the future.
Employment History
Lisa has a sporadic employment history. She has worked primarily in retail and warehouse positions. Her longest employment was for two years at a department store. Over the past three years, she has struggled to maintain steady employment due to her substance use and associated health issues. Lisa is currently unemployed and expresses a desire to find stable work to support herself and her son.
Readiness for Treatment
Lisa voluntarily sought treatment following a near-fatal overdose, indicating movement toward the Preparation stage of change. She recognizes the detrimental effects of her substance use on her health and relationships. Lisa expresses motivation to change but also exhibits ambivalence due to fear of withdrawal and uncertainty about coping mechanisms. She acknowledges the need for professional support and is open to engaging in treatment services.
Strengths, Resources, and Responsibilities
Lisa is eligible for Medicaid, which can cover treatment costs. She has a stable living arrangement with her friend Maria, who offers a drug-free environment. Lisa demonstrates insight into her condition and expresses a willingness to participate in therapy. She has vocational skills and a history of academic achievement, which can be leveraged in her recovery process.
Client's Stated Goals and Desired Outcomes
Lisa aims to achieve sobriety and regain custody of her son. She desires to manage her chronic pain through non-opioid means and improve her mental health. Lisa wishes to rebuild relationships with her family and establish a stable living situation. She expresses interest in returning to school or obtaining employment to become financially independent.
Current Mental Status Summary
Lisa is a 28-year-old African American woman who appears her stated age. She presents with appropriate attire and adequate grooming. She is cooperative during the interview and maintains eye contact. Lisa's mood is subdued, and her affect is constricted. She demonstrates coherent thought processes but exhibits signs of anxiety when discussing her substance use. Her speech is normal in rate and tone. Lisa is oriented to time, place, and person. She demonstrates intact long-term memory but reports difficulty with concentration and short-term memory, likely due to substance use. She denies hallucinations or delusions. Lisa does not express suicidal or homicidal ideation.
Diagnostic Impressions Summary
Based on the assessment, the following diagnostic impressions are noted:
Opioid Use Disorder, severe
Unspecified Depressive Disorder
Chronic back pain
Legal issues related to substance possession
Strained familial relationships due to substance use
Initial Recommendations
Lisa exhibits readiness to engage in treatment services. It is recommended that she participates in a medically supervised detoxification program to manage withdrawal symptoms safely. Following detoxification, enrollment in an intensive inpatient rehabilitation program is advised to address her opioid dependence comprehensively. A multidisciplinary approach should be employed, incorporating individual psychotherapy to explore underlying psychological issues contributing to her substance use. Cognitive-behavioral therapy may assist in developing coping strategies for pain management and emotional regulation. Lisa would benefit from group therapy sessions to build a support network and reduce feelings of isolation. Participation in family counseling could facilitate communication and repair relationships with her mother and siblings.
A referral to a psychiatrist is recommended for a formal mental health evaluation to determine the need for pharmacotherapy for her depressive symptoms. Non-opioid pain management strategies should be explored in collaboration with a pain specialist. Vocational rehabilitation services can assist Lisa in re-entering the workforce or pursuing educational opportunities. Coordination with legal services is necessary to address her probation requirements and prevent further legal complications.
Service Plan
Individual Therapy: Twice weekly
Group Counseling: Daily participation in substance use recovery groups
Family Counseling: Weekly sessions with mother and siblings
Medical Evaluation: Immediate referral for detoxification and pain management
Psychiatric Consultation: Evaluation for depressive symptoms and treatment planning
Vocational Rehabilitation: Enrollment in job readiness programs