Date:
Patient:
Reason for Visit: Follow-up for stimulant use disorder (SUD)
Presenting Concerns: ( Briefly summarize the patient’s current concerns and motivations for treatment)
History of Present Illness:
Onset and duration of stimulant use (e.g., cocaine, amphetamines, methylphenidate)
Route of administration (e.g., snorting, injecting, oral)
Frequency and quantity of recent use
Presence of withdrawal symptoms (if applicable)
Impact of stimulant use on daily life (work, relationships, health)
Any co-occurring mental health conditions (depression, anxiety, ADHD)
Substance Use History:
Explore past and present use of other substances (alcohol, cannabis, etc.)
History of treatment attempts for SUD (rehab, medication)
Social History:
Living situation (supportive, chaotic)
Employment status
Legal history (related to substance use)
Mental Status Exam:
Briefly describe the patient’s mood, affect, thought processes (e.g., pressured speech, racing thoughts)
Assess for suicidal or homicidal ideation
Assessment:
Diagnose stimulant use disorder based on DSM-5 criteria (severity level)
Identify potential triggers for stimulant use
Consider any co-occurring mental health diagnoses
Plan:
Outline the treatment plan:
Psychotherapy: (e.g., cognitive-behavioral therapy (CBT), motivational interviewing (MI)) to address cravings and triggers.
Medication-assisted treatment (MAT): Explore options like stimulants for ADHD or non-stimulant medications to reduce cravings (if appropriate).
Support groups: Encourage participation in 12-step programs (NA, SMART Recovery) or other support groups.
Referral to additional services: Consider referrals for vocational rehabilitation, legal aid, or mental health services for co-occurring conditions.
Discuss expectations for treatment and potential challenges.
Follow-up:
Schedule the next appointment date.
Identify any safety concerns and develop a safety plan (if needed).
Additional Information:
Document urine drug screen (UDS) results, if applicable.
Note any collateral information from family members or significant others.