Upon intake, our qualified clinician completed a Risk, Need and Capacity assessment, with risks clearly identified and service delivery modified accordingly — for example, larger rooms and flexible engagement strategies where there was a risk of aggression. To build trust, case management was used to demonstrate immediate outcomes and actions, such as a dental referral.

A Self-Sufficiency Matrix was used to identify the client's top three priority needs and assess their level of insight and self-awareness. Using the FISH model, foundational needs were addressed first to stabilise the client and reduce their crisis state.

Upcoming legal matters were identified, including a significant risk of incarceration and no legal support. A referral was made to our collaborating lawyer and a support letter outlining the client's treatment plan was provided to assist with court proceedings.

Harm-reduction strategies and psychoeducation were introduced to address substance use, including sessions focused on how addiction affects the brain. A provisional ADHD assessment was also completed. The client was supported to attend a GP appointment and referred to a specialist psychiatrist partnered with SAMMs.

To remove financial barriers, funding was provided for the specialist assessment at no cost to the participant. The client was subsequently diagnosed with ADHD and commenced treatment. Once substance use and ADHD symptoms were being effectively managed and the participant had become stabilised, SAMMs was able to assess baseline functional capacity and explore ongoing cognitive concerns.