Social Work Case Study 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.

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.

Mental Health Update: Client was diagnosed with Clinical Depression and client reported she wasn’t attending her mental health counseling at BATF (“Bridging Access to Care”).

Housing Update: client NY NY I, II was approved. Client is waiting for DHS manifest to tour apartment. Another alternative housing is MRT once client SSI is approved. Client also mentioned she signed up with Brightpoint Health Home Health Services since 5/9/2015, Client report she will like to sign up with CAMBA/Home Health and she provided BrightPoint Home Health approval letter for CM to submit to CAMBA/Home Health Coordinator. Client is waiting for her coordinator at Brightpoint to return from vacation to close her case, so that she can sign up with CAMBA/Home Health

Kris is a 65 year old white female. She is currently an entrepreneur and also the manager to five of her children. Kris has a convenient lifestyle. She has a house and gets frequent visits from her children, kimberly (age 34), khloe (age 32), kourtney (36), Rob (age 29), Kendall (age 20), and Kylie (age 19).

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

Meeting is arranged for Tuesday, September 20, 2016. Client continues to report not even her coordinator she gave him a copy of her psychosocial and psychiatric evaluation. She also mentions that her coordinator is requesting for client to be removed from his

Client stated that she understands. Case Manager also explained to client that once she becomes eligible she will be expected to obtain permanent housing by 08/2017. Client stated that she understands.

SOCIAL SUPPORT UPDATE: Client reported she wasn’t feeling well. She has bronchitis and takes prescribed medication. CM inquires if the client got in touch with her children and sister. Client replies “her children live in Florida and she doesn’t know the whereabouts of her sister. She also reported no community support.

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

The patient was placed on HOLD to see the writer to address his non-compliance with treatment. The patient was reminded about his Step 3 of the patient engagement. According to the patient as the writer reviewed the patient case history of his no show for counseling, group attendance, and continuously AWOL, the patient only response was, " I, know." The writer then inquired of the patient efforts to engage in mental health services through ICRC. The patient admits that he haven't done the intake when the deadline was extended for the third time. The writer discussed with the patient about the risk of facing an intent to discharge due to his non-compliance and addressed alternatives such as suboxone and transferring to a clinic in Massachusetts to accommodate the work location. The patient declines the writer's suggestion as he wants to remain with HCRC-Hartford due to the positive treatment and said. " You guys really care....I do not want to be discharge.....I, mean what is the process of the intent of discharge?" The writer explained to the patient about the appeal process as his record will be reviewed by the Practice Manager to determine as to whether or not to forward with the discharge or the discharge to be overturn.

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.

Client reported feeling down within the last month and using heroin to cope. Client also reported feeling better and motivated towards the end of the month. Client completed a Beck Depression Inventory in which he scored a 6 indicating normal ups and downs. Client VA records confirm a diagnosis for PTSD and the medication list includes, Sertraline and Setraline HCL, as well as methadone to which the client appears compliant. Client reported he is medication compliant. Client denied any S/I or H/I.

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.

CM received report from LAMP VASH worker Laurie Garza regarding client’s missed appointment on 11/25. LAMP VASH worker Laurie Garza inquired about client’s drug use and general well-being due to client’s lack of motivation. LAMP VASH worker suggested client explore different housing programs due to client’s resevations regarding weekly meetings with case manage . CM will discussed new housing referral options with client. CM will notify Laurie Garza about client’s decision regarding housing program.