LATE ENTRY
CM was out on vacation from the period of 5/31/2017 to 6/14/2017. On 6/20/2017, CM met with the client to complete Bi-Weekly ILP Review. In the meeting client was satisfactorily groomed and dressed appropriately for the weather. Client affects and mood was inappropriate. Client continues to denied suicidal or homicidal ideation. Client reported she wasn’t feeling well and she was given “Bed Pass”. CM observed that the client sometime can appears to be manipulative and she will always find excuses for her behavior.
In the meeting client complain about resident D. James /K-4 immaturity and how that resident will complain about everything client do. CM advises the client not to confront resident K-4 and to report whatever confrontation to staff.
Client continues to report her biological mother
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Client indicated that she suffers from asthma NOS with Acute Exacerbation, allergies rhinitis, insomnia, unspecified. Client reported no changes in her medications and she is seen by Dr. Muhammad M. Haque/PCP.
Client reports depression and anxiety/panic attacks, and she is currently participating individual mental health session at NY Psychotherapy Mental Health located at 102 Pilling St, Brooklyn, New York 1x a week. (Tuesday @ 3pm). Client report no changes in her medications; and she also doesn't want for Staff to monitor her prescribed psychotropic medications:
Citalopram HBR 20mg (1x daily), Clonazipam 2mg (1x daily), albuterol (as needed), Ventolin (as needed), ondonsetronorally disintegrating tablet 8mg (as needed), ibuprofen 800mg ( as needed), Benadryl 25mg ( as needed) fluticasone propronate 50mg 1 daily.
Client is currently attending individual mental counseling at 102 Pilling Street, Brooklyn, New
York and Dr. Adam Antione/psychiatrist. Client meets with her therapist 1x a week (every Tuesday).
Client continues to reports no history of alcohol abuse but reports substance
I: CM guided client through ISP goals. CM inquired about updates related to the client’s housing goals. CM used open ended questions to inquired about the client most recent drug use. CM reminded client that starting Monday the 2nd he would have to meet with CCM for weekly case management going forward. CM continued to assess for PTSD symptoms, substance abuse, and medication compliance.
CM was out on vacation for the period of 8/15/2015 to 8/24/2015. On 9/1/2015, CM met with the client to complete Bi-Weekly ILP Review. Client arrived early for the meeting. She was alert, satisfactorily groomed, and casually dressed. She was cooperative and appropriate in the meeting. She made eye contact appropriately. The client described her mood as “good” Her affect was in appropriate. She doesn’t appear to be in distress. CM inquires how the client has been doing since the last Bi-Weekly ILP Review. Client replies “ she is good”. She continues to relate she doesn’t make anyone aggravate her. She also mentioned lately one of her male friend graph hole of her cell number, and he calls her every day. CM inquires how it got hold of her cell# client replies “she doesn’t know”. CM advised the client if he continues to harass her two things she can do: One file a police complain or change her cell number.
On 8/1/2015, CM met with the client and completed Bi-Weekly ILP Review. CM inquires the reason client wasn’t available for face to face meeting. Client reported she had a scheduled doctor appointment the same day. Client in the meeting appeared her stated age. She was alert, satisfactorily groomed, and casually dressed. She was cooperative and appropriate in the meeting. She made eye contact appropriately and her mood was balanced and her affect was appropriate. The client is fluent in French and CM called the Language Translator.
I-CM informed the client that he had contacted and left a message with LA Family Housing the week prior, but no one answered due to the Thanksgiving holiday. CM contacted LA Family Housing again with the client present, but on one answered and a voice message was left. CM continued to assess client’s mental health and medication compliance. CM inquired what outside activities the client has been engaging in. CM inquired about client’s plans for Thanksgiving.
CM was out on vacation for the period of 8/15/2015 to 8/24/2015. On 8/26/2015, CM met with the client to complete Bi-Weekly ILP Review. Client arrived a few minutes late. She was dressed appropriately for the weather. She was well groomed. She was cooperative and friendly. She appeared in good health. CM inquires how client has been doing since the last Bi-Weekly ILP Review. Client reported she went to Tillary Women’s Shelter for her personal belongings; unfortunately she was unable to retrieve all of her personal belongings. She was asked to come back on 8/27/2015 Client reports no community support.
The purpose of this meeting is to complete case management intake forms. Client arrived fifteen minutes early to appointment. Client was in a good mood this afternoon. Client stated pampering themselves due to getting from new employment. Client was also laughing and joking around during the case management intake meeting. Client seemed very happy today. Client attire was presentable; client wore sandals due to getting a pedicure and client clothes were clean. Client stated working as a home health aide for Right at Home located Darien. Client stated to this CM working Friday at 12:00 PM to Monday at 12:00PM. This CM inquire how client is doing and client stated to this CM doing good. Client reported to this CM working in New Canaan as a Home
On 4/6/2016, CM met with the client to complete Bi-Weekly ILP Review. In the meeting client was dressed in a brown jacket and beige pants and black sneaker. She was wearing reading glasses. During the session client reported she wasn’t feeling well she have a strep throat for the past 8 days. She reports coughing, fever and sore throat.CM inquires if the client met with the on-site medical staff client replies “No”. CM advises the client to see on-site medical staff. Client in the meeting was repeating the same things over and over.
CM was out on vacation for the period of 11/25/2016 to 12/12/2016. Client was scheduled to meet with CM on 12/13/2016, to complete Bi-Weekly ILP Review. Client was no show. CM inquire the reason client was no show. Client replies “she wasn’t feeling well and she went to LIJ Emergency Room. On 12/15/2016, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed with proper attire for the weather. She was well-mannered and groomed. In the meeting client appears to be cooperative
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
Your client Sue is a Social Work Assistant. In your last session she disclosed that she is concerned that on a recent home visit, herself and a senior colleague did not follow the necessary policies and procedures. They had visited a family with a history of neglect and domestic violence and did not ask to see the child or enter the home, both these actions are prescribed as appropriate as part of their work.
Prescription Drugs – This list can be quite exhaustive, but mainly contains all the tablets prescribed by the GP with regards to depression, sleeping tablets e.g. Tamazepan, Diazepam, and Valium
Mental Health: Wellness Coach asked Mr. Hallet if he has any therapist appointments coming up and he express that his next appointment is on 12/20/2016 at 10:30am. Wellness Coach asked Mr. Hallet how he been managing his depression and he responded that he been active and walking daily. He been adherent to the medication but he wishes not to take them. In asking Mr. Hallet what is causing him to stop taking them and he states that it brings back vivid images that is causing him to form bad thoughts. Wellness Coach then asked if he is going to harm people or himself. Mr. Hallet
Using a symptom checklist the client is currently experiencing sad moods (3 times weekly), bouts with(several times throughout the day daily), difficulty sitting still (9-10 times daily), difficulty staying focused (9-10 times daily) bad dreams (nightly), blames self for trauma (nightly), negative feelings about self (3-4 times weekly) and physically fight others (once a week). The client denies any current suicidal or homicidal thoughts.
Kling to become a Licensed Clinical Psychologist, she did her internship at St. Luke's Roosevelt Hospital. Dr. Kling ran supervision groups at The Village Institute for Psychotherapy and these include case conferences and intensive supervision along with providing psychotherapy to patients on a sliding scale. She works four full-time, long hour days seeing clients for 45 minutes with a 5minute break in between if possible. Dr. Kling sees 6 to 8 patients a day on average. As a psychologist in NY, Dr. Heidi Kling takes much pride in the expert help and counseling she is able to offer her clients. Dr. Kling noted that she helps clients with relationship issues, eating disorders, psychotherapy, depression, anxiety, loss and grief counseling, and couples counseling. When asked about her background and experience and how they compare with employers' expectations when hiring an MHC, Dr. Kling noted that she has a lot of experience working with different kinds of patients with a variety of pathologies and different levels of mental health functioning. She also does work using a combination of psychodynamic, insight-oriented and cognitive behavioral approaches and problem-solving strategies. Even though her practice does not supervise interns she sometimes supervises graduate students who are treating patients at their graduate school clinic or externship. Dr. Kling was also an adjunct Clinical Supervisor at The Derner Institute for Advanced Psychological Studies, Adelphi
AT has been seen in therapy for 2 years now. She had a psychiatric assessment at Toronto Western Hospital in 2012 and then was put in the waiting list for psychodynamic psychotherapy. Her goal of doing therapy as she stated in the assessment that she wants to deal with "depression" that started early in her life at the age of 15.