Client Report Sample

On 6/30/2016, CM met with the client to complete to Bi-Weekly ILP Review. In the meeting, client was dressed appropriately for the weather. She was very loquacious and client. Client appears to have difficulty sustaining attention, client does not seem to listen when spoken to directly and she is unable to follow through on tasks. Client affect is inappropriate and she denied suicidal or homicidal ideation.

He reports the patient’s roommate was subsequently evicted from his home after the landlord inquired about the ambulance visiting. He reports he contacted her father concerning the patient residing within the family home, but the father has said no. In addition, he reports he has attempted to contact her uncle but has been unable to make contact with him. He reports he has attempted to make contact with her said friend who is considering allowing her the opportunity to reside with her but she has not answered her phone and he has been unable to leave a voice message. He reports no one wants her in their home, and the patient has “burned her bridges” with family members. He reports her family would benefit from counseling. In addition, he reports her family has high expectations of CPS. He reports her current case was not going to close within 12 days of 06/30/2017. In addition, the case will not

Medical: Ms. Williams failed to submit her medical documentation. Ms. Williams is expected to submit her medical evaluation or physical by 03/2017. Case Manager explained to Ms. Williams that if she failed to submit the documents required she would be considered as non-compliance.

On September 21, 2012, ACEDS Case Action Update/Display documented by Social Service Representative, Richard Gordon stated that Ms. Williams arrived to the agency to apply for Supplmental Nutrition Assistance Program (SNAP) benefits, and Medicaid for her child only. During the visit, CARE interface revealed that Ms. Williams had an open Medicaid case in Maryland (#47403882500). Maryland Social Services also reported that she was employed by CPR Medical as of August 9, 2012, and paid bi-weekly $850.00. Ms. Williams also reportedly received unearned monthly income from SSI in September 2012 in the amount of $440.34, and in October 2012, in the amount of $370.54. As a result, Ms. Williams was denied expedited Foodstamps pending paystubs and her application was marked as "pending."

On 2/11/2016, CM met with the client for Bi-Weekly ILP Review. Client appears to be cooperative and friendly. She was alert, satisfactorily groomed, and casually dressed. She was very loquacious.

Social Services Meeting: On 03/01/2017, Ms. Hawkins and her daughter Emoni met with her assigned Case Manager for the family ILP Document Review. Ms. Hawkins’ next ILP Document Review appointment is on 03/14/2017. Ms. Hawkins is in-compliance with the terms of her ILP. Ms. Hawkins was reminded that she is expected to attend all scheduled meetings with assigned Case Manager and failed to do it would considered non-compliance and warning will be issued. Ms. Hawkins stated that she is aware. Case Manager asked Ms. Hawkins if there are any issues or concerns that she will like to discuss, Ms. Hawkins stated no.

As you know, this case is established for the low back with an average weekly wage of $578.90. The claimant has been classified with a permanent partial disability and payments are continuing to him at the marked rate of $289.45. By Notice of Decision filed on 01/10/2007, Section 15(8)(d) was established in this case.

On 7/11/2015, CM did a visual and had client come to the social service office. CM completed Bi-Weekly ILP Review. In the meeting client appears to be wear out, and tired. She was constantly throbbing her forehead, like if she was having headache. CM inquires what the problem is. Client replies “she doesn’t like the shelter food and sometimes she doesn’t eat” CM advised the client to eat and nourished her body. CM also observed that client is depressed but she continues to refuse medical referral to see a psychiatrist and medical doctor. Client continues to mention her son who is in foster care, and the physical altercation she sustained many months ago here at this shelter. CM mentioned to the client she was a transferred from another shelter due to physical altercation, CM continues to relate to the client she

CM was out on vacation from 5/3/2017 to 6/14/2017. On 6/20/2017, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed in proper attire for the weather. Her affect and mood was appropriate. Client maintains eyes contact appropriately and she was oriented to person, place, time and situation. Client continue to deny suicidal or homicidal ideation

Hair is expected to submit medical document for her and her child by 02/2017. Ms. Hair failed to submit updated medical documentation. Case Manager reminded Ms. Hair if she failed to submit the document required on her next meeting it would be considered non-compliance and a warning for non-compliance will be issued. Ms. Hair stated that she was aware.

On 7/11/2015, CM met with the client for Bi-Weekly ILP Review. Client arrived early for the meeting. In the meeting client appears to be well groomed with good hygiene and dressed appropriately for her age. She was calm, cooperative and well related. She discussed typical issues re: her political and activism work and automobile accident disbursement. She continues to relate her paralegal was in the neighborhood and she wanted this worker to meet her. Unfortunately, there was no parking and she left. She also mentioned the paralegal brought her documents that she need to filed with the state and the federal for her automobile entitlement.

On 8/7/2015, CM met with the client and completed Bi-Weekly ILP Review. Client arrived early for the meeting; she was alert, satisfactorily groomed, and casually dressed. In the meeting she was cooperative and friendly. CM inquires how client is doing since the last Bi-Weekly ILP Review. Client reported she is exhausted from running around obtaining relevant documents to be submitted to Lemle & Wolfe, Inc. by 8/3/2015. She continues to reports she has Straight Medicaid and she is searching for a Managed Cared that cover oxygen tanks.

I sent the forms to the member on 06/06/2016 as per request but she doesn’t want to fill them out. She went to the Medicaid office (115 Chrystie St., NY, NY 10002) on Wednesday June 8,2016 and they informed that her case is being handle and not further documentation is needed. Medicaid Office gave this case # 0237738221E. That’s the reason why she doesn’t want to fill out further documentation.

Adrian is a 24-year-old Caucasian male who presents to CRU from RRC-W. He is ACOT for non-compliance. He is SMI designated. La Frontera is the outpatient treatment agency for Adrian. He also receive DD services from AZ Dept of Development Disabilities. Per amendment letter, client was being aggressive towards group home staff, and admitted to stating that he wanted to jump into traffic. He denies AVH, and DTO. His BP is elevated 139/81, he has a hx of HTN and high cholesterol. He will benefit from meeting the provider to discuss medication

SC completed monitoring telephone call with Pa on 1/20/2016. SC called Pa. Pa reported that ding “good”. Pa reported no new health problems, no medications, no falls, and no hospitalizations. Pa reported no outstanding doctor’s visits. Pa reported that’s he saw her PCP on 1/19/2016. SC reviewed Pa's ISP. Pa confirms that she is receiving services in the following type, scope, amount, frequency and duration of services specified in the ISP agency model aide via Total Home Health Care from 10-2PM, Monday through Sunday. Pa's aide provides assists her with the completion of ADLs, IALDs and supervision as needed. Pa has PERS system which gives her access to emergency medical service. Pa also, receives HMD from PCA weekly. She reported being satisfied