CM normally meets with the client every Wednesday for scheduled meetings. CM inquires the reason client was no show on 7/20/2016, Client replies “she has a doctor appointment.” On 7/21/2016, CM met with the client to complete Bi-Weekly ILP Review. In the meeting
Client was alert, satisfactorily groomed, and casually dressed. She was very loquacious. She made eye contact appropriately. Client’s mood was in appropriate. She was oriented to person, place, time and situation. Client appears to have satisfactory fund of general knowledge for her situation. Client denied suicidal or homicidal ideation.
SOCIAL SUPPORT: CM was informed by other CM that the client came to the social service requested for other staff to input her late passes. CM
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informs the client if CM is not around she must meet with Social Service Supervisor for help. In the meeting client appears to be upset. CM inquires the reason client was upset. Client replies “She is upset with the onsite RN, because she went to see the onsite medical staff for follow up hospital discharged. Client continues to report she was in pain and onsite medical staff inquires if the client is complaint with her medication Flexeril (muscle relaxer and Naproxen). Client continues to report some medications she cannot take it during the day because is muscle relaxer and she will be unable to function. Client continues to relate she was upset with the RN when she told her to take ½ of the medication to help with the pain. RESOURCE UPDATE: Client continues to report she has an active PA case. Food Stamps $115.00 and Cash $35.00/bi-weekly. EMPLOYMENT UPDATE: Client reported last week she is no longer employed at Paramour Decorator and she was recently was employed at Flying Food Group located at JFK Airport her work hours are as follows: Friday to Tuesday. 2pm-10:30pm. Her supervisor is Norman and the HR contact is Judy; telephone number (718 307-8022. Client late passes was approved for the following days 7/22/2016, 7/23/2016, 7/24/2016, 7/25/2016 and 7/26/2016,until 2:am. Client reported to this worker that she is not staying employed too long at Flying Food Group because the job is too stressful.
She continues to report she applies at Bed Bath & Behind and an interview is scheduled for 8/5/2016. Client reported she was unable to submit any copy of pay stubs because she just started this work and she gets pays bi-weekly.
SAVING: Client reported she was unable to save any money this week due to changes in job.
LEGAL UPDATE: client continues to report ongoing lawsuit against Women's Shelter due to a shoulder injury she sustained while residing at the previous shelter. Client didn’t disclose any additional information.
MEDICAL UPDATE: Client continues to report shoulder, neck, and left arm pain, numbness. She also reported dizziness and sore finger. Client report she goes for pain management and Spine Specialist. Client also sees Neurology. She also reported last week she picks her a copy of the blood work and Vitamin D deficiency and everything is ok. Client reported Vitamin D deficiency is on the border line. SHE also reported follow up appointment with her PCP today and with the Spine doctor 8/5/2016 and Neurology 7/27/2016. Client reported no changes in medications.
MENTAL HEALTH UPDATE: Client continues to reports no mental health issues.
SUBSTANCE ABUSE UPDATE: Client continues to reports no substance abuse
history. HOUSING: Client is a GP and her housing package is completed and circulated. Client also has an active LINC V voucher. Client this week didn't submit copy of housing search log. Client report onsite HS/Lockhart help client apply for housing with CAMBA. REVIEW ILP AND CLIENT REIGHTS AND C LIENT CODE OF CONDUCT VIOLATION: CM reiterates the shelter rule and regulation and for the client to adhere 10pm curfew. CM also advises the client if she has any issues or concern to see an administration. WORKER ASSESSMENT OF CURRENT SITUATION: CM observed that the client is set in her way. She shows the following personality; she will threaten staff to go to the Coalition or Upper Management. She let staff know how knowledgeable she is of the shelter rule and regulations, & DHS rule and regulation. Client continues to have the ability to identify and complete goals in a timely fashion. Furthermore, she is capable of living independently or in a SRO with no help. PLAN OF ACTION: Client must submit copy of pay stubs, client submit housing search log, and Client must adhere to the 10pm curfew and to DHS Rules and Regulation. Client must participate in all scheduled meetings. Client must attend to all on-site and off-site medical appointments and provide medical documentations. Client must adhere to the saving contract. Client must provide updated information concerning her legal issue. CM reviewed the Bi-Weekly ILP. Client agreed and signed. Next Meeting is scheduled for 8/3/2016.
She sent in works to the Salon and they were accepted but received no comment. She then sent in...
She had a two week history of feeling generally unwell, complaining of tiredness and lethargy. She had no other significant symptoms. Her past history includes well controlled asthma and anxiety. She was a smoker of 20 cigarettes per day. She was taking amitriptyline, Symbicort (budesonide and formoterol inhaler). She had no significant family history of medical illness and had no clinical findings on examination. Blood tests showed corrected calcium of 4.22mmol/L (NR 2.20 -2.60) with suppressed paired PTH of 1.45pmol/L (NR1.60- 6.9). Her renal function was initially impaired, but normalized with rehydration. Her liver function tests, full blood count, vitamin D, myeloma screen and serum ACE levels were all within normal limits. Ultra sound scan (USS) of kidneys, USS of parathyroid and computerized tomography (CT) of thorax, abdomen and pelvis were all reported as normal with no cause found for her
Mr. James has arrived for his assessment at the Gadsden County Human Services office. His demeanor is somewhat different from the last meeting. He is more reserved today and seems to be open to effective communication. The case manager, Tameka Footman enters the room and greets Mr. James. Mrs. Footman asks Mr. James, how he’s feeling about the session today. Mr. James responds and says that he’s feeling good about it. Mrs. Footman reviews the events that took place last session and asked if there were any questions from the previous meeting. Mr. James says that he doesn’t have any questions are is eager to get started.
Diagnosing a patient with a personality disorders where often evaluations done by a clinician. The clinician would listen to the importance of interpersonal experiences and observing the patients behavior in a consulting room (Westen, 2001). This was normally done in one session, if the patient informed the clinician of harming himself. The clinician would diagnose the patient as a borderline personality disorders.
On 6/23/16 the client Cristina Maldonado #130 did not show up or contact her assigned worker for the scheduled ILP meeting .Case Manager went to unit #130 and meets with Ms. Maldonado and inquired about her noncompliance her weekly meeting; she stated that she has no reason to come for her meeting because she don’t think anyone is helping her here. CM remind client that if she do not attend her meeting is difficult for staff to assist her needs. Client has been refusing to sign any appointments slips and warning. In addition Ms. Maldonado writes messages in her warning using profaned language. CM reminds client that she is expected to comply with all shelter and DHS rules and regulations while residing in the shelter system. Client is fully
III. REASON FOR SEEKING CARE (CC): 38 y/o female c/o abdominal pain throughout the entire abdominal cavity, states she has always had abdominal discomfort, but the past 3 days’ pain has become unbearable. Describes pain as a burning churning through out 8/10. Pain intermittent c/o of sour stomach after meals accompanied by nausea, denies vomiting, diarrhea or anorexia, last bowel movement 4 days ago. States she moves bowels 2-3 times a week. She states this happened about 2 years she went to emergency room, CT was done, no blockage, she was sent home without meds, CT contrast helped her move bowels at the time, symptoms eventually resolved on their own. Pt c/o of waking up feeling unrested, had trouble falling asleep ever since she could remember, wakes up frequently with difficulty getting back to sleep. She reports sleep disorder sometimes coincide with inability to get comfortable due to shoulder and neck pain especially in the winter months. Pt states the head and shoulder pain are the result of a MVI in 1995 where she had spinal nerve damage and bulging disc.
A visit note from Masahisa Amano, MD (Family Medicine), dated 11/03/2017, indicated that the claimant presented for a post ER follow-up visit with a sharp pain in the back radiating down to his right hip/leg. He stated that Ibuprofen and Cyclobenzaprine provided minimal relief. His blood pressure was 132/79. He was diagnosed with a back pain and abnormal liver function tests. A repeat of lab tests was recommended.
Mr. Allison, the client is a 28-year-old white male with long blonde hair. He is well groomed and have facial hair. He was dressed in a brown suit and tie. He had his hair in a ponytail. He just got off work and was in his uniform. He came with his ford car keys in his hand. Mr. Allison is a 28 years old white male. He looks his age and has an average height and weight. He looks calm and relax. He wore a refreshing perfume and looks very polished. He came from a loving family. His parents were married for over 30 years and never been divorced. He has one sibling named Mark, with whom he is very close. Mr. Allison has an associate degree in computer science and programming. He works as a sales lead in a European company. He was in several relationships but is currently single.
The client, Ali, is a 15 year old white female attending high school and living in North Kingstown, Rhode Island. She lives with her biological father, but her family system also includes her brother, Larry, biological mother, Carol, and maternal grandmother, Lucinda. She is in overall good health and there was no mention of any physical health concerns. However, based on the descriptions given by her relatives and Ali herself, as well as observations from the first meeting, Ali shows signs of anxiety, depression, and some difficulties understanding social cues.
When the therapist met the client in the office for individual therapy, the client greeted the therapist and he was feeling good and energetic as he reported as evidence by reporting that he had a good time with his friends during the previous weekend and he is excited to meet the psychiatrist for follow up and tell the psychiatrist about why he is tired, bored, and sleepy most of the time. Client reported that the lowest moment of the week was when I did not pay my cell phone bill because he does not have money and the group home manager did not allow him to use the Wi-Fi as a consequence for not following the house rules as he reported that he did not do his chores. Client reported that he was overwhelmed and busy for the previous couple
Behavior (B): The session took place in TC’s family’s home. Mother presented with appropriate affect and euthymic mood. Mother was receptive to counselor’s comments and questions and provided feedback to counselor when necessary. Mother was well groomed, focused, alert, oriented x4. Mother had no signs of delusions, hallucinations or suicidal ideations. The home was clean and appeared safe.
The client's mother was emotionally unavailable and never stepped in to intervene during the father's violent rage. The client witnessed domestic violence as a child and also personally experienced years of abuse from her husband. The client had two children with her soon to be ex husband, a son and a daughter, as well as two grandkids. She reports a having frequent contact with her children, however, she describes their relationship as distant. Both of her parents struggled with alcoholism but the client denies any alcohol abuse. The client's experiences made her develop low self-esteem and low confidence as well as difficulties trusting others. Regina cannot maintain healthy relationships and has problems interacting with others
Symptoms/behaviors observed/reported during this service: Client shared he was upset, due to being placed o house arrested. Client was frowning and crossing his arms.
Met with client for ISP review and to discuss recovery progress. Client arrived to scheduled session on time with normal mood. Client updated her
For the next two months, from 10/31/2016 to December 31,2016, apply for jobs each week and document in note book the name of company and date after application is completed