Mental Health Case Study
LATE ENTRY
On 5/4/2017, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed in proper attire for the weather. Client affect was rapid. Client mood was loquacious. She appears to be fatigue, and restless. CM insures what going on. Client reported lack of sleep due to the shelter environment. She also mentioned not eating well and she also states she is restless because she will like maintain herself occupy and due to her immigration status she can find a job and she requested for this worker to assist her in obtaining source of income and she will like to do pay volunteer job here at the shelter.
CM inquires if the client has any social support. Client reported she does have children residing out of state, and her …show more content…
Client mentions she suffers from the following medical conditions Hypertension, and depression.
Client reported mental problem and she is currently attending individual session with Ms. Olga Vazquez-LCSW/Mental Health Clinician affiliated with the Institute for Family Health located at 16 East 16th St, New NY 1003 tel# 212-2065200.
On 4/3/2017, client met with the onsite psychiatrist doctor and she was diagnosed with Axis! Severe episode of recurrent major depression d/o, without psychotic features; F33.2 (primary)
PTSD (post-traumatic stress d/o) F43.10, r/o
Dysthymia; F34.1, r/o
Social phobia; F40.10, r/o and for the client to continues therapist with Dr. Vasquez. And she was prescribed with Trazodone 50mg at bedtime as needed for sleep.
Client is aware she is not entitled to any government assistant and she will need to move out the shelter independently.
CM reiterate the shelter rule and regulation and for the client to adhere to DHS Code of Conduct and to 10pm curfew.
Client continues to show sign of being worn out and sad. CM emphasizes to the client to attend to all medical appointments, and participate in a mental health services. CM reviewed and translated the Bi-Weekly ILP Review by using Google Translate. Client agreed and signed the Bi-Weekly ILP Review. Next Bi-Weekly ILP is scheduled for
On 5/4/2017, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed in proper attire for the weather. Client affect was rapid. Client mood was loquacious. She appears to be fatigue, and restless. CM insures what going on. Client reported lack of sleep due to the shelter environment. She also mentioned not eating well and she also states she is restless because she will like maintain herself occupy and due to her immigration status she can find a job and she requested for this worker to assist her in obtaining source of income and she will like to do pay volunteer job here at the shelter.
CM inquires if the client has any social support. Client reported she does have children residing out of state, and her …show more content…
Client mentions she suffers from the following medical conditions Hypertension, and depression.
Client reported mental problem and she is currently attending individual session with Ms. Olga Vazquez-LCSW/Mental Health Clinician affiliated with the Institute for Family Health located at 16 East 16th St, New NY 1003 tel# 212-2065200.
On 4/3/2017, client met with the onsite psychiatrist doctor and she was diagnosed with Axis! Severe episode of recurrent major depression d/o, without psychotic features; F33.2 (primary)
PTSD (post-traumatic stress d/o) F43.10, r/o
Dysthymia; F34.1, r/o
Social phobia; F40.10, r/o and for the client to continues therapist with Dr. Vasquez. And she was prescribed with Trazodone 50mg at bedtime as needed for sleep.
Client is aware she is not entitled to any government assistant and she will need to move out the shelter independently.
CM reiterate the shelter rule and regulation and for the client to adhere to DHS Code of Conduct and to 10pm curfew.
Client continues to show sign of being worn out and sad. CM emphasizes to the client to attend to all medical appointments, and participate in a mental health services. CM reviewed and translated the Bi-Weekly ILP Review by using Google Translate. Client agreed and signed the Bi-Weekly ILP Review. Next Bi-Weekly ILP is scheduled for