Progress Review- Rayvon Bush Please list outcomes of any/all drug screens. Please include the date, type, results, and substance (if applicable) Not applicable Progress in treatment: (please choose either moderate-significant-slight improvement, or moderate-significant-slight deterioration, or no change) ISSUE PROGRESS Emotional Regulation Slight Improvement. Client able to express himself and his feelings to be able to understand the reason behind his aggression. Family Functioning No change. Client is currently spending the summer outside of his guardian’s house. Please include any/all changes or updates in diagnosis: Current diagnosis: AXIS I: 314.9 Attention-Deficit/Hyperactivity Disorder NOS AXIS II: No changes AXIS III: No changes AXIS IV: Primary Support Group GAF: No changes Please list any/all medications: (please include dose amount, frequency, prescribing physician, and target symptom) Current meds include: Prozac 15 mg- 1 tablet Abilify 15 mg- 1 tablet Have other medications been tried and discontinued since last review? If yes, please list medications and response to them. No. Is the client in danger to himself or herself or someone else due to mental illness or …show more content…
MT has build rapport with the client to help him with stress management strategies and coping skills. The client is currently staying with another family member for the summer and through this change of environment has allow the client to accept the treatment and work on bettering himself as the client has had no behavior incident since being discharge from Dover Behavioral Health to his other family member house. The client’s MT will continue to provide the client resources to help him control his emotion and express himself to others, which would provide help when he moves back with his guardian. In addition, the MT will assist the client’s guardian in improving communication with
The intervention that was implemented was the invitation for the father to participate in the therapeutic sessions with his son and ex-wife. I explained the client’s recent behavior and the subsequent admittance to my agency. I clarified that the client’s behavior worsens after their divorce which is evidenced by the increased disciplinary infractions he received at school. The client also became more combatant and argumentative with his mother and siblings as reported by them. I proposed the idea of meeting for a family therapy session to uncover the cognitive reasons behind the
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
will schedule an appointment to discuss and create a budget plan. Patient is currently free from all illicit drugs, which has helped her Adderall medication to be more beneficial. Primary Counselor will encourage Pt. to follow through with all mental health appointments. Counselor will prompt Pt. to develop a positive self-image. Pt. has denied having any auditory or visual hallucinations during the last quarter as evidenced by group and individual session notes. Pt. has had some setback in achieving her goals of decreasing her family conflicts and resolving intimate relationship issues. Counselor will encourage Pt. to attend the AMS parenting group and share her expectations regarding having a more functional family unit. During the next quarter therapy sessions, Counselor will utilize role-playing, role reversal, modeling, and behavioral rehearsal to assist Pt. in order to develop positive ways to resolve conflict with ex-husband. Pt.’s current treatment plan goals focus on opiate use disorder, financial, mental health services and parent-child relational problems. During the upcoming quarter, current goals will continue to be
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.
The client?s wife asked him to seek help and made the appointment with a VA psychiatrist as well as myself (LCSW) and took him to his initial appointments.
The patient has mental issues that lead to physical harm and violence to others. The therapist is obligated to report Don’s threats and have him checked into a facility to prevent any crimes being committed.
Client has been discharged from OP/TSF services under PBH due to the significant progress of his treatment goals. The client is current in the transition of being adopted was to receive services from another agency for OP therapy. Due to the different transition in the client life, it was recommend the client continues to receive OP therapy from New Behavioral Network to help him with his upon coming adoption in December 2016.
(B) Discuss how it would be best to handle this, including the best outcome for the client.
The client is being more involved in his treatment by helping to create rules for his household and monitor his behavior.
• Case manager needs to discuss disengaging with the patient or significant other and capacity to listen to their fears and or concerns.
Please list outcomes of any/all drug screens. Please include the date, type, results, and substance (if applicable)
The client is aware of her emotions and how they affect her relationship with her husband and children. Her awareness of her unstable mental health situation will be useful later when these emotions are addressed in counseling.
Therapy needs to be dialed in and positives need to be given to his medication so he will start to get better and have less episodes.
There are several ethical dilemmas that the mental health professionals that are working as a team will face including “ensuring that the client has given informed consent, maintaining client confidentiality, and involving professionals, paraprofessionals, and family in appropriate coordinated processes that benefit the client” (Paproski & Haverkamp, 2000, p.96).
Due to this client having schizoaffective disorder, PTSD and abandonment issues and has had no known incidents of recent alcohol or drug use;