Hope Ctr Records — USA v. Jittaphol (Dkt. 34-4, D. Mass.)

Summary

Document 34-4 in Case 1:21-cr-10270-MLW, filed 01/28/22, is 21 pages of Hope Center clinical stabilization services records for Aticha Jittaphol, beginning with an admission note dated 12/13/2021. The note records a referral from Carlson Recovery Center with a primary diagnosis of amphetamine use disorder and states that Jittaphol is on federal probation, which requires further treatment.

Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used

Record facts

Full text

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Hope Center - Clinical Stabilization
Services Admission Note

Session Information

Client: Jittaphol_, Aticha (260293) agai

Staff: Hall, Erin (006952)

Document Date: 12/13/2021

Client Program: (Not Set)

Clinical Stabilization Services Admission Note

Date of Admission:
Admission Details:

Strengths:
Needs:
Abilities:
Preferences:

42/13/2021

(D) Ms. Aticha Jittaphol was referred to Hope Center from Carlson Recovery
Center with primary diagnoses of Amphetamine Use Disorder. She denies any
secondary diagnoses or interest in obtaining MAT. She is currently on federal
probation and denies any appointments. Ms. Jittaphol would like to return home
however probation requires further treatment.

} Ms. Jittapho! presented as friendiy, calm and engaged.

P) Ms. Jittaphol is assigned to room #10A and primary counselor is Erin/Colleen.

Ms. Jittaphol reports "
Ms. Jittaphol reports "
Ms. Jittaphol reports "
Ms. Jittaphol reports "

Client DSM Diagnosis as of 12/13/2021
03:08 PM

Client: Jittaphol , Aticha (260293) Camis

Effective Date/Time: 12/13/2021 03:08 PM

External Diagnosis: No

Diagnosed By: Hall, Erin (006952)
Comments:

Diagnosis

DSM-5 Severity/Specifier iCD-10 Comments

F15,20 -
Stimulant
Use
Disorder,
Severe,
Amphetamine-
type
substance

F15.20 -
Other
stimulant
dependence,
uncomplicated

The Diagnoses above display in priority order.

Psychosocial and Contextual Factors

iCD-10 Code - Description

Comments

265.3 - Problems Related to Other Legal Circumstances federal probation

Diagnostic Formulation

No records found.

Signatures

Signature #1: | Erin Halt (No Primary Credential) - 12/13/2021 3:30 PM

Signature History

Action Date Staff
Document Signed 12/13/2021 Erin Hall (No Primary
Credential)
Jittaphol , Aticha (260293) 1 of 2 Date Printed: 1/3/2022 10:51 AM
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Hope Center - Clinical Stabilization
Services Admission Note

Addenda
Narrative _Signed By
S$ - "good with meditation, understand other Erin Hall (No Primary Credential) -
people, kind." 12/13/2021 3:46 PM

N - "Ido not need anything.”

A- "sports, business, organization.”

P - “be successful, take care of my family and
return home."

Jittaphol , Aticha (260293) 2 of 2 Date Printed: 1/3/2022 10:51 AM
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#544 P.004/022

Hope Center - BHN Episodic
information

Session Information

Client:

Jittaphol , Aticha (260293) GUA

Staff:

Hall, Erin (006952)

Document Date: 12/15/2021
Client Program: (Not Set)

BHN Episodic: Housing, Employment, Financial, Education

What name do you use?

What pronouns do you
use?

Other Pronouns:

What type of housing
do you and your family
live in?

Is anyone worried or
concerned that the next
two months you may
NOT have stable
housing?

Housing Stability
Details (please
elaborate):

Describe Current
Employment Status:

Employment Details
{please elaborate):

Do you or anyone in
your household receive
financial assistance?

Other Financial
Assistance:

Level of Schooling:

School Name and City:

Review Status:

Name and Pronoun
Aticha

She/Her/Hers

Housing
Private residence, client owns or holds lease (Rent)

Yes

Aticha currently rents her own apartment in the Boston area.

Employment
Self-employed (Business owner)

Aticha reports she is the owner of her own massage business.

Financial Assistance
If you receive any financial assistance identify below.

fm) None OC Retirement Fund 0 Transitional Assistance
Ossi CISNAP/Food Stamps Other (family and
O ssp1 C1 Child Support friends)
(J Unknown / Person
Declined

Education
What is the highest degree or tevel of schoo! you have completed?
Technical/Vocational degree (electrician, welding, hvac)

Aticha is a licensed massage therapist and has her certificate.

No information Copied Forward From Prior Document

-BHN Episodic: Military and Disability

Military Service

Military Service: | Have you ever served or currently serving in active duty in Armed Forces,

Jittaphol , Aticha (260293)

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Family Military History:

Other Details:

Disabitity:

Other Disability (Please
elaborate):

Date of Last Physical
Exam:

Provider and Clinic:

Date of Last Dental
Exam:

Provider and Clinic:

Review Status:

P_.005/022

Filed 01/2

8/22. Page4of
01/26/2022 #

Hope Center - BHN Episodic
information

Reserves, or National Guard?

© Yes

@ No

if you have any immediate family members in the military, identify below
fei No O Parent DO Children

C1 Legally Married Spouse (7 Grandparent D Other

O Partner, Significant
Other (unmarried)

Disability
If you have any of the following disabilities identify below
fi] None 0 Mobility difficulties [J Neurocognitive

C1] Serious hearing CT Developmental dementia) (TBI,
difficulties with hearing disability w/o

aid intellectual disability C1 Learning disability (ie.
[Legally blind/vision CJ Developmental gysioxia, dyscalcutia
difficulties with adaptive _—_ disability w/ intellectual *
equipment disability 0 Other (please
elaborate)

Medical and Dental Exam Information
If exact date is known record that
November 2021

Fenway Health

If exact date is known record that
November 2021

Howard University Dental School

No Information Copied Forward From Prior Document

BHN Episodic: Substance Use Discovery

Tobacco:

Substance Use History:

Recovery Support:

Recovery Support How
Often:

Jittaphol , Aticha (260293)

Tobacco Use History
Have you used any tobacco product in the last 30 days?
No

Substance Use History

Have you, or has a relative, friend, doctor, or other healthcare worker been
concerned about your drinking or drug use or suggested you cut down?

Yes

Who is your recovery support?

fl Family and Friends ( Recovery Coaching [J Unknown
(1 Community (AA, NA, [None
Self-Help)
How often do you receive the support?
3-6x /week
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Hope Center - BHN Episodic
information

Review Status: | No information Copied Forward From Prior Document

BHN Episodic: Legal

Legal
Do you have advanced | © Yes
directives established? ®No
Do you h have any of the | ) Self / Competent C) Healthcare agent/proxy 1 MOLST (MA Medical
‘ollowing to help you Order for Life
with financial, medical, | Rep Payee Ol Durable Power of Sustaining Tx)
or personal decisions? ( Conservatorship y CODNR (Do Not
(J Rogers Order Resuscitate)
Q Other
Other:
Do you have a legal | i=] Self / Competent oO State Appointed Legal (0) Caregiver Affidavit
guardian 0 is your C Parents uardian Cl) Other
legal guardian? [J State Agency Legal
Guardian (DCF, DMH,
DDS)
Other Guardianship:
Review Status: | No Information Copied Forward From Prior Document

Signatures
Signature #1: | Erin Hall (No Primary Credential) - 12/15/2021 3:12 PM

Signature History

Action Date Staff
Document Signed 12/18/2021 Erin Hall (No Primary
Credential)

Jittaphol , Aticha (260293) 3 of 3 Date Printed: 1/3/2022 10:51 AM
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01/26/2022 15:00

Hope Center - BHN Diagnostic
Information

Session Information

Client: Jittaphol_, Aticha (260293)
Staff: Hall, Erin (006952)
Document Date: 12/15/2021

Client Program: (Not Set)

Referral Source:

Referral Source Details:

Reason for Current
Referral or Continuing
Service:

Person's Desired
Outcomes for
Treatment:

Symptoms / Behavioral
/ Emotional Needs:

Describe Current Status
of Functioning:

Additional Information:

BHN Diagnostic Assessment: Referral

Referral
BHN

Include Name, Agency, Phone Number if referred by anyone other than self. If
self, type “self” below,

Carlson Recovery Center
What brought you here? What kind of additional services are needed?
Aticha was brought to Hope Center due to probation however desires change.

What are you hoping to accomplish by the end of treatment?
Aticha reports she wants to find a way to heal herself and complete treatment.

Check any identified needs and describe significant history and current status of
functioning in the box below.

CZ) Adjustment to Stressors 1] Homelessness C] Psychosis

C) Anxiety O impulsivity / CD Relational Challenges

(Behavioral Disturbance Hyperactivity C2 Self-Harm

C1 Conduct D1 Inattention CJ] Sleep Disturbance

CD) Depression / Dysthymia O Legal ; CD Social / Sexual

C Development Concerns CO] Mania / Hypomania Concerns

( Driving Under Influence C Mood Disturbance C3] Substance Use

C Eating Disturbance Oo Obsessions / C] Thought Disturbance

Compulsions C Traumatic Event

[1 Emotional! Control " umatic Event(s)
C] Opposition C Other

O Grief 0 Phobia

Include specific symptoms, frequency, duration and severity, and impact on
functioning.

Aticha reports having used substances since 2013 however the usage didn't
escalate until the last 3-4 months.

BHN Diagnostic Assessment: History and Current Presentation

These are prompting questions to complete this section, please follow guidance
from your program. Prompting questions are to assist in gaining information on
the impact to the current individual served.

Developmental History

Developmental History: | Aticha reports meeting all milestones growing up.

Education / Occupational

Education /| Aticha reports having graduated high school and obtained a certificate in

Occupational:

Jittaphol , Aticha (260293)

massage therapy. She is currently licensed to be a massage therapist. Aticha has
worked in a restaurant to help support her friend however does not have much
experience elsewhere until working as a massage therapist.

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From:

Family Retationship:

Further Family
Assessment Needed?

Community Integration:

ff you use different
name/pronouns other
than your legal name,
do you want this in the
record?

Are you okay with us
sharing this information
with your parent(s),
providers, and others?

Sexual Orientation and
Gender Identity:

Trauma History:

individual's Strengths:

Review Status:

44 P.008/022

o1 15:00 #5

Hope Center - BHN Diagnostic
Information

Family Relationship
Aticha was born and raised in Thailand. She came to the Untied States in 2010
for an internship and returned in 2012 after graduation of school. Aticha reports
that her parents never divorced and continues to have a wonderful relationship
with them. Her family is really close and she reports they are heavily supportive
of her. She reports having younger brother and in continually communication with
him as he lives in Thailand.

If yes complete family assessment.
O Yes

@No

Community Integration

Aticha reports being involved with a volleyball team. She reports enjoying
meditation and working with her business - being successful.

Aticha reports she finds pleasure in her social group and relationships with her
peers. They are very supportive to her and she finds support through them.

Sexual Orientation and Gender Identity

Yes

No

fucha identifies as a transgender female. She denies any issues or concerns at t
is time.

Trauma History
Aticha denies any trauma history at this time.

individual's Strengths

What do you consider your strengths?

What do you think you are good at?

What has worked for you to solve problems?

What CANS domains are currently or could become potential strengths?

Aticha reporis her strengths as meditation, playing volleyball, patience, learning,
honesty, business and working hard.

No Information Copied Forward From Prior Document

BHN Diagnostic Assessment: Judicial Involvement

Do you have a history
of, or current
involvement with the
legal system (i.e., legal
charges)?

Legal Charges:

Jittaphol , Aticha (260293)

Judicial Involvement

@ Yes

ONo

D1 Abuse C1] Dependency Oj oul

CO Armed Robbery (J Drug Possession (J Pan Handling

C1 Assault and Battery ( Harassment C1 Protective Custody

OC Burglary (1 Neglect [? Protective Services

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From:

Event Date/End Date (if
Known):

Status:

Outcome:
Name of Court:

Name of Probation
Officer and Phone
Number:

Other Details:

Add Additional
Charges:

Judicial Involvement
Other Detaiis:

Hope Center - BHN Diagnostic
Information
XD Restraining Order C1 Threatening Other
D Theft ( Trespassing
4/14/2021
Pending

Maureen Curran - 617-655-2818

Aticha is currently on federal probation for Distribution of Class B and PPE fraud.
O Yes
© No

Current involvement and Mandated Reporting

Current Involvement by:

Comments:

Additional Mandated
Report Required?

Comments:

Has a Children
Requiring Assistance
(CRA) petition been
filed?

CRA:

Review Status:

f] None CO Elder Affairs 7 Section 35
C2 Department of Children 1 Disabled Person's 1 Other

and Families Protection Commission
fi None TD Elder Affairs CJ Other

C Department of Children ( Disabled Person's
and Families Protection Commission

Children Requiring Assistance (CRA)

Information on this page may have copied forward from a previous document.
Please indicate the status of this information below.

No Information Copied Forward From Prior Document

BHN Diagnostic Assessment: Mental and Physical Health History

Niental Health History and Treatment

Relevant Mental Health | Aticha denies any past mental health.

Jittaphol , Aticha (260293)

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History and Treatment:

Past Mental Health
Symptoms Worth
Noting:

Current Mental Health
Treatment:

Physical Health:

Medication:

Other Details:

Review Status:

01/26/2022 15:01 #544 P.010/022

Hope Center - BHN Diagnostic
Information

Aticha denies any past mental health.

Current Mental Health Treatment
Aticha denies any current mental health.

Physical Health
Include inpatient, Detox, CCS, EATs, PHP, Outpatient, Other

Aticha reports having Hepatitis B.

Medication

List any relevant previous or current medication (Psychiatric and Medical,
Rationale/Condition, Dosage/Route/Frequency if known).
Spironolact / 100mg / 1 tab oral 2x daily

Other Details

Information on this page may have copied forward from a previous document.
Please indicate the status of this information below.

No Information Copied Forward From Prior Document

BHN Diagnostic Assessment: Substance Use History and Treatment

Substance Use History and Treatment

Have you ever
overdosed?

Describe how many
times and if Narcan was
administered.

Have you ever
witnessed an
overdose?

Describe who (family,
friend) and when.

Does the person know
how to recognize an
overdose and know
what to do if they
witness an overdose?

Describe the person's
current understanding
of how to avoid an
overdose.

Jittaphol , Aticha (260293)

Overdose Screening
O Yes

@® No

O Yes
@®No

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From:

Relevant Substance
Use History and
Treatment:

Current Substance Use
Treatment:

Case 1:21-cr-10270-MLW Document 34-4

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Hope Center - BHN Diagnostic
information

Substance Use History

Type of service (Outpatient, Residential, Inpatient/Detox, Court Mandated, Other
Treatment etc.), date of service, reason, name of provider/agency, past
diagnosis, was the treatment helpful?

Detox / x1 / Dec 2021 / Carlson Recovery Center

Current Substance Use Treatment

Type of service (Outpatient, Residential, Inpatient/Detox, Court Mandated, Other
Treatment etc.), date of service, reason, name of provider/agency, current
diagnosis, is the treatment helpful?

Hope Center CSS

For Persons Considering an Opiate Treatment Program, complete this

Tobacco Assessment
Completed?

Infectious Disease Risk
Assessment
Completed?

Tuberculosis
Assessment
Completed?

Further Substance
Assessment Needed?

Other Comments
Regarding Substance
Use:

Review Status:

American Society of Addiction Medicine
Admission for the Followi

box
C) Applicable

If no, complete applicable assessment.
@ Yes

O No

If no, complete applicable assessment.
@ Yes

ONo

If no, complete applicable assessment.
®@ Yes

ONo

if yes, complete applicable assessment.
O Yes

@® No

Other Details

(include SU by other family members/significant others, SU related legal
problems, and stage of treatment information):

information on this page may have copied forward from a previous document.
Please indicate the status of this information below.

No Information Copied Forward From Prior Document

(ASAM) Degree of Severity at
ng Dimensions

| NA
Intoxication/ Biomedical Emotional’ Readiness to Relapse/ Recovery Family
Withdrawal/ Conditions/ Behavioral/ Change Continued Environment Functioning
Potential _Complications Cognitive . _Use Potential (Youth Only)
0 - None 1 -Low 0 - None 1-Low 3 - High 3 - High
Jittaphol , Aticha (260293) § of 9 Date Printed: 1/3/2022 10:52 AM
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From:

Substance Abused:

Route of
Administration:

Frequency:
Amount:

Age First Used:
Last Used Date:
Explain:

Priority #:

01/26/2022 15:01

Hope Center - BHN Diagnostic

Information
Substance Abuse Entry
Amphetamines/Stimulants
Smoked
3-6x / Week
$30-$40
12/4/2021

Describe Types/Amount Used

BHN Diagnostic Assessment: Mental Status Exam and Risk Assessment

Appearance:

Behavior / Functioning:
Mood / Affect:

Thought Process /
Orientation:

Further Mental Status
Exam Needed?

Danger To Self, Other,
or Property?

Risk Behavior?

Further Risk
Assessment Needed?

Mental Status Exam
Clothing, Eye Contact, Build

Aticha is dressed appropriately and maintained eye contact throughout the
session. She appears to have a healthy body weight.

Body Movement, Speech, Facial Expression, Posture

Aticha spoke fluently and remained upright throughout the session.
Emotionai State 4

Aticha appeared to be upbeat and engaged.

Perception, Hallucinations, Delusions, Intellectual Functioning,
Judgement, Insight, Reasoning

Aticha appeared to be oriented.
O Yes
@ No

Memory,

Risk
O Yes
@ No

Risk Behavior
© Yes

@ No

O Yes
@ No

BHN Diagnostic Assessment: Interpretative Summary / Assessments

Interpretative Summary:

Jittapnol , Aticha (260293)

Interpretative Summary

What in your clinical judgement are the need areas, the factors that led to the
needs, and your plan to address them?

Ms. Aticha Jittaphol is a 32 year old transgender female, who was referred to
Hope Center from Carlson Recovery Center with primary diagnoses of
Amphetamine Stimulant Use Disorder. She denies any secondary diagnoses or
interest in MAT. Aticha is currently on federal probation and in continual

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Hope Center - BHN Diagnostic
Information
communication with her PO. She currently rents her own apartment and is the
owner of her own business. Atichia's chronic substance use, and probation, has
lead her to believe her life needs redirection and assistance back on track.
Based on the initial assessment, the central themes that will need to addressed in
CSS level of care are:
vi potential for further relapse.
#2) legal issues.
#3) aftercare.
The anticipated challenges Aticha will need to focus on while she is in CSS level
of care are:
#1) risk management, identify relapse triggers.
#2) remain in continual contact with probation.
#3) follow stipulations put forth by court (further treatment or obtain an IOP).
Assessments Administered During this Session
__ Assessments | I] None E) COLUMBIA C1 Infectious Disease Risk
Administered During | 7 aRiZONA CIDSMS SUD Criteria _ Assessment
this Session: Ss Tob:
OAsups urvey obacco
COBPRS O ESM /BSAS Cj UNCOPE
CCANS Ci Family QD) Other
C1] GAIN
Other Details:
Further Assessments Recommended
Further Assessments | [i] None [] COLUMBIA C] Infectious Disease Risk
Recommended: | ry arizona [1 DSM& SUD Criteria Assessment
OAsups Survey (Tobacco
COBPRS oO ESM /BSAS [ UNCOPE
CICANS 0 Family C Other
(1 GAIN
Other Details:
Further Evaluations/
Assessments
recommended outside
BHN:
Client DSM Diagnosis as of 12/15/2021
03:13 PM
Client: dittaphol_, Aticha (260293
Effective Date/Time: 12/15/2021 03:13 PM
External Diagnosis: No
Diagnosed By: Hall, Erin (006952)
Comments:
Diagnosis
DSM-5 Severity/Specifier ICD-10 Comments
F15.20 - F15.20 -
Stimulant Other
Use stimulant
Disorder, dependence,
Severe, uncomplicated

Jittaphoi , Aticha (260293)

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From

Amphetamine-

type
substance

01/26/2022 15:01 #544 P.014/022

Hope Center - BHN Diagnostic
Information

The Diagnoses above display in priority order.

Psychosocial and Contextual Factors

1CD-10 Code - Description

Comments

265.3 - Problems Related to Other Legal Circumstances _ federal probation

Diagnostic Formulation

No records found.

Recommendations
Recommendation Domain / Need Statement Person Status
Desires
Change
Now? .
ALL SUD Substance Use - "It started outas Yes Active
Substance Use fun but became a habit. | started
struggling and it took me out of
thinking about the struggling."
ALL SUD Legal - "Il am on probation." Yes “Active
ALL SUD Transition/Aftercare/Discharge -"} Yes Active

Transition/Aftercare/Discharge

have my own place."

BHN Diagnostic Assessment: Level of Care and Treatment

Will person's family be
involved with
treatment?

Who in family will be
involved with
treatment?

Crisis Services:

1-Service Type:

1-Specific Clinical
Support Service:
1-BHN Referral?

1-BHN Site:
1-Additional Comments:

Jittaphol , Aticha (260293)

Recommendations
@ Yes

ONo

If yes, specify (include family's response to recommendations, the involvement of
family in the assessment process, state agency involvement and other supports).

Treatment Recommendations

im) N/A C) Referrat to Crisis Cj Requested Mobile
Ci Called Ambulance for [] Referred to Emergency Crisis Assessment
Transport to ED Department for
Assessment
@ Clinical Supports O Other © Support Services

Clinical Support and Stabilization (CSS)

Yes

Hope Center

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Hope Center - BHN Diagnostic

Information
2-Service Type: | O Clinical Supports O Other © Support Services
3-Service Type: | © Clinical Supports © Other © Support Services
4-Service Type: | © Clinical Supports © Other © Support Services

Additional Services Recommendation Comments
Additional Services | It is recommended that Atchia follow all stipulations of probation and obtain an
Recommendation | aftercare plan that aligns with counseling and probation recommendations.
Comments:

Response

Person Served/ | Aticha agrees to the previously stated recommendation.
Guardian/Family
Response to
Recommendations:

Signatures

Electronic | Only Hall, Erin (006952) or their supervisor can sign this
Signature: | document.

Signature History

Action Date Staff
Document Signed 12/15/2021 Erin Hall (No Primary
Credential)

Jittaphol , Aticha (260293) 9 of 9 Date Printed: 1/3/2022 10:52 AM
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Hope Center - |AP-SUD

Session Information

01/26/2022 15:02

Client: Jittaphol , Aticha (260293)
Staff: Hail, Erin (006952)
Document Date: 12/15/2021
Client Program: (Not Set)
IAP--SUD
Initial or Review: | O Initial © Review
Plan Begin Date/Time: | 12/13/2021
04:47 PM
Next Pian Due In| 45
(Number of Days):
Pian End Date/Time: | 01/27/2022
04:47 PM

#544 P.016/022

Client Program(s):
Reason For Referral:

Strengths/Needs/
Abilities/Preferences:

fs) Clinical Support Services (CSS)

Ms. Aticha Jittaphol was referred to Hope Center from Carlson Recovery Center
with primary diagnoses of Amphetamine Use Disorder, She denies any
secondary diagnoses or interest in obtaining MAT. She is currently on federal
probation and denies any appointments. Aticha would like to return home
however probation may require further treatment.

S - “lam good with my work and am independent"

N -"I need to stop smoking meth and take better care of myself

A-"l| work hard and take care of my parents financially in Thailand"

P - "| want to put all of this behind me and if I stop smoking meth, | can move on
from this and go back to my life”

Problems/Goals/Objectives

Status of Goal

Domain 1: Legal - “l am on probation.”
Program: ALL_ SUD

Goal 1: “Speak to probation officer regularly, and talk to my lawyer.” Active

Progress Toward Goal: n/a
Completed Date (date will take goal off plan):

Objective 1: Aticha will work with her primary counselor, in
conjunction with her probation officer, to ensure transparency
that she follows stipulations put forth by the court. She will
actively participate in all forms of treatment, and will sign all
releases necessary in order to maintain full contact with her
probation officer. Aticha will take random urine screens while at
the Hope Center CSS level of care and will maintain contact with
her probation officer.

Client Programs: Clinical Support Services

Start Date: 12/13/2021

Progress Toward Objective: n/a

Completed Date:

Minimal
Progress (20%)

Domain 2: Substance Use ~ "It started out as fun but became a habit, I
started struggling and it took me out of thinking about the struggling.”

Program: ALL SUD

Goal 1: "Learn about my mind/body and why | turned to using
drugs."

Progress Toward Goal: n/a

Completed Date (date will take goal off plan):

Active

Objective 1: Aticha will participate in ail groups and meet with
her counselor 3x weekly for 1:1 counseling sessions. She will
maintain abstinence and participate in random urine screens /
breathalyzer tests as requested. She will be responsible for

Jittaphol , Aticha (260293) 1 of 3

No Progress
(0%)

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Hope Center - JAP-SUD

completing homework assignments, formulate a relapse
prevention plan and participate with primary counselor to
review the homework.

Client Programs: Clinical Support Services
Start Date: 12/13/2021
Progress Toward Objective: n/a
Completed Date:
Domain 3: Transition/Aftercare/Discharge - "I have my own piace.”
Program: ALL SUD
Goal 1: “To get back home and do an outpatient program." Active
Progress Toward Goal: n/a
Completed Date (date will take goal off plan):
Objective 1: Aticha will work with aftercare specialists to No Progress
discuss her aftercare plan, which will be determined by her (0%)
treatment progress. Depending on the progress, Aticha will
complete referrals for further programming or complete OP
referrals.
Client Programs: Clinical Support Services
Start Date: 12/13/2021
Progress Toward Objective: n/a
Completed Date:

Interventions
Intervention 1: Legal - Hope Center will provide releases for Aticha in
order to maintain contact with her probation officer. Hope Center will also
provide random urine screens and provide them to probation if needed.
Primary counselor will meet with Aticha individually to provide support
and guidance as well as to optimize contact between corresponding
parties.
Service: Individual Daily Support
, Individual Therapy/Counseling
, Nursing
, Group Therapy
Start Date: 12/13/2021
Responsible Party:
Completed Date:
Intervention 2: Substance Use - Aticha will be provided with daily psycho-
educational groups, primary counselor will meet with her 3x a week for 1:1
individual sessions, will also be provided random urine screens/
breathalyzer tests and homework assignments.

Service: Group Therapy

, Individual Daily Support

_ Individual Therapy/Counseling

, Nursing

Start Date: 12/13/2021

Responsible Party:

Completed Date:

Intervention 3: Transition/Aftercare/Discharge - Aftercare specialists will
work with Aticha to identify her aftercare plan. Depending on treatment

progress, aftercare will send referral to My Sisters House and coordinate
an interview or complete an {OP referral.

Service: Group Therapy

, Individual Daily Support

, Individual Therapy/Counseling
Start Date: 12/13/2021
Responsible Party:

Completed Date:

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Hope Center - IAP--SUD

Signatures

Adee Sillaplo
Signature Date Time: | 12/15/2021 8:31 PM

Signatory: | Jittaphol , Aticha (Self)
Enter New Signatory: | (if unavailable)

Signatures:

Signature #1:

Erin Hall (No Primary Credential) - 12/15/2021 8:31 PM
Signature #2:

Debra Trueax (No Primary Credential) - 12/21/2021 2:36
PM

Signature History

Action Date Staff

Document Signed 12/18/2021 Erin Hall (No Primary
Credential)

Document Signed 12/21/2021

Debra Trueax (No
Primary Credential)

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Hope Center - Clinical Stabilization
Services Discharge Summary

Session Information

Client: Jittaphol, Aticha (260293) Me

Staff: Fenton, Colleen (007843)

Document Date: 1/3/2022

Client Program: (Not Set)

Date of Discharge:

Strengths, Abilities,
Needs and Preferences:

Discharge Destination:

Reason for Seeking
Treatment:

Interventions/
Responses:

Outcomes:

Jittaphol, Aticha (260293)

Treatment Summary
01/27/2022

Upon admission, Ms. Jittaphol's strengths, needs, abilities and preferences were
assessed as follows:

S - "good with meditation, understand other people, kind.”

N - "I do not need anything.”

A- "sports, business, organization."

P-"be successful, take care of my family and return home.”

Upon completion they were assessed as follows:
S - To focus on self.

N- To stay away from people who are using.

A- To reach out to a friend to get to a meeting.

P - To remain abstinent.

Home

Treatment Summary

Ms. Aticha Jittaphol was referred to Hope Center from Carlson Recovery Center
with primary diagnoses of Amphetamine Use Disorder. She denies any
secondary diagnoses or interest in obtaining MAT. She is currently on federal
probation and denies any appointments. Ms. Jittaphol would like to return home
however probation requires further treatment.

Include information on interventions/services provided and person's response to
interventions.

Ms. Jittaphol was subject to numerous groups including daily process groups and
psycho-educational groups with such topics as Motivation, Relapse Prevention,
Overdose Prevention, Recognition and Response, Anger Management,
Spirituality, Nutrition, Stages Of Change and Coping Skills, compulsive behaviors,
Living Sober, and Roadmaps, (treatment plan goals/ review). Ms. Jittaphol also
participated in 1:1 one-hour counseling sessions, several times a week. Ms.
Jittaphol attended AA/NA meetings that came into the facility. Ms. Jittaphol
actively participated in all groups, inside the house as well as individual sessions.
She responded well to ail interventions and participated in all aspects of
programming. Ms. Jittapho!l responded well to all most of Treatment as indicated
in the outcome listed below.

Include qualitatve and quantitative information regarding progress/gains

achieved, strengths, abilities and preferences, Specify any standardized
measures used.

Based on the initial assessment, the central themes that will need to addressed in
CSS level of care are:

#1) potential for further relapse.

#2) legal issues.

#3) aftercare.

The anticipated challenges Aticha will need to focus on while she is in CSS level
of care are:

#1) risk management, identify relapse triggers.

#2) remain in continual contact with probation.

#3) follow stipulations put forth by court (further treatment or obtain an IOP).

Ms. Jittaphol made great strides in areas of developing coping skills, gaining
insight as evidenced by increasing participation in groups and individual
counseling sessions. Ms. Jittaphol aiso showed improved insight through
homework assignments, listing high-risk events that could trigger relapse, long-
term and short-term goals for recovery, employment, interpersonal relationships,

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Hope Center - Clinical Stabilization
Services Discharge Summary

and purpose. Ms. Jittaphol and her primary counselor reviewed these materials in
detail in an effort to extract insight and solutions to her long term substance use.
Ms. Jittaphol met with aftercare, however, when presented with options for long-
term treatment in a residential facility or being set up with IOP Ms. Jittaphol was
very closed-minded, and refused both.

ASAM (American Society of Addiction Medicine)

(Readiness to Change: Use Prochaska's Stages as Scale)

Intoxication/Withdrawal
Potential:

Biomedical Conditions/
Complications:
Emotional/Behavioral/
Cognitive:

Readiness to Change:

Relapse/Continued Use
Potential:
Recovery Environment:

Financial:
Vocational/Educational:
Legal Issues:

0 -None
1-Low |
4 -Low

3 - Preparation
3 - High
3 - High

Status at Discharge
Ms. Jittaphol is currently unemployed.

Ms, Jittaphol has no vocational/educational needs at this time.
Ms. Jittaphol is on Federal Probation and is in the pretrial phase. |

Housing: | Ms. Jittaphol has an apartment in Boston.
if homeless, what was done to avoid discharge to a shelter?
N/A
MAT Received: | [] Methadone (1 Other C1 Vivitrol
li None (1 Suboxone
Narcan Given: | [J Yes C] No i N/A
Goals Addressed
iAP--SUD
Mark as Domain/Goal/Objective Status Comments / Plan
Addressed
Domain: Legat - "am on probation." _
fll Addressed Goal: "Speak to probation officer individual Actively Ms. Jittaphol was
regularly, and talk to my lawyer." Engaged compliant with the
stipulations of
probation while in
CSS level of care.
f@ Addressed Objective: Aticha will work with — Individual Actively Ms. Jittaphol signed "

releases and
provided drug testing
upon request. She
had the opportunity
to remain in contact
with probation.

her primary counselor, in
conjunction with her probation
officer, to ensure transparency
that she follows stipulations put
forth by the court. She will
actively participate in all forms
of treatment, and will sign all
releases necessary in order to
maintain full contact with her
probation officer. Aticha will take
random urine screens while at
the Hope Center CSS level of
care and will maintain contact
with her probation officer.

Engaged

Jittaphol, Aticha (260293)

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Hope Center - Clinical Stabilization
Services Discharge Summary

Domain: Substance Use - "It started out as

fun but became a habit. | started struggling

and it took me out of thinking about the

struggling."

Hl Addressed Goal: “Learn about my mind/body and Individual Actively Ms. Jittaphol
why | turned to using drugs.” Engaged remained abstinent

while in CSS level of
care,

il Addressed Objective: Aticha will participate Individual Actively Ms. Jittaphol actively
in all groups and meet with her Engaged participated in
counselor 3x weekly for 1:1 groups and met with
counseling sessions. She will counseling staff for
maintain abstinence and 1:1 sessions to
participate in random urine discuss her recovery
screens / breathalyzer tests as Status. She provided
requested. She will be drug test upon
responsible for completing request and worked
homework assignments, on homework
formulate a relapse prevention assignments.
plan and participate with
primary counselor to review the
nomework.

Domain: Transition/Aftercare/Discharge - "I
have my own place."

f@) Addressed Goal: "To get back home and do an Individual Declined Ms. Jittaphol met

outpatient program." with aftercare staff,
however declined
long-term residential
treatment and IOP.

i@ Addressed Objective: Aticha will work with — Individual Declined Ms. Jittaphol refused
aftercare specialists to discuss to complete referrals
her aftercare plan, which will be and stated that she
determined by her treatment only wanted to return
progress. Depending on the home.
progress, Aticha will complete
referrals for further
programming or complete |OP
referrals.

Mark as intervention Status Comments / Plan

Addressed

a] Addressed _ Intervention: Legal - Hope Center will Caregiver Actively Hope Center staff

provide releases for Aticha in order to Engaged remained in contact

maintain contact with her probation officer. with Federal

Hope Center will also provide random urine Probation

screens and provide them to probation if Department

needed. Primary counselor will meet with regarding Ms.

Aticha individually to provide support and Jittaphol. Hope

guidance as well as to optimize contact Center provided drug

between corresponding parties. screen and provided
to probation officer.

I] Addressed _Intervention: Substance Use ~- Aticha will be Caregiver Actively Hope Center staff

provided with daily psycho-educational Engaged provided psycho-
groups, primary counselor will meet with educational groups
her 3x a week for 1:1 individuat sessions, and met with Ms.
will also be provided random urine screens/ Jittaphol for 1:4
breathalyzer tests and homework counseling sessions.
assignments. Ms. Jittaphol was
provided with
homework
assignments for her
to work on, Drug
screen provided.
ll Addressed Intervention: Transition/Aftercare/Discharge Caregiver Actively Hope Center

Jittaphol, Aticha (260293)

30f4

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From
Hope Center - Clinical Stabilization
Services Discharge Summary
- Aftercare specialists will work with Aticha Engaged aftercare staff met
to identify her aftercare plan. Depending on with Ms, Jittaphol in
treatment progress, aftercare will send an effort to put out
referral to My Sisters House and referrals and/or set
coordinate an interview or complete an IOP up IOP for her upon
referral. completion of the
Hope Center.
Goals Addressed: j Utilizing the objectives and interventions, Ms. Jittapbhol met some of the goals set
forth in her treatment plan. Transition/Aftercare/Discharge plans were not met.
Client DSM Diagnosis as of 1/3/2022 11:43
AM
Client: Jittaphol, Aticha (260293) 1 a
Effective Date/Time: 1/3/2022 11:43 AM
External Diagnosis: No
Diagnosed By: Fenton, Colleen (007843)
Comments:
Diagnosis
DSM-5 Severity/Specifier ICD-10 Comments
F15.20 - F15.20 -
Stimulant Other
Use stimulant
Disorder, dependence,
Severe, uncomplicated
Amphetamine-
type
substance

The Diagnoses above display in priority order.
Psychosocial and Contextual Factors

ICD-10 Code - Description Comments

265.3 - Problems Related to Other Legal Circumstances federal probation

Diagnostic Formulation

No records found,

Signatures

Signature #1: | Colleen Fenton (No Primary Credential) - 1/3/2022 12:08
PM

Next Staff To | Only Trueax, Debra (010250) or their supervisor can sign
Sign: | this document.

Signature History
Action Date Staff
Document Signed 1/3/2022 Colleen Fenton (No
Primary Credential)

Jittaphol, Aticha (260293) 4 of 4 Date Printed: 1/26/2022 2:28 PM


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