Discharge Summary and 1 page- Documents attached to help complete.

Course: HN330

Assessment Form

Client Name: Bo Crabtree

Date of Birth:

08/25/2003

Date of Assessment:

06/26/2017

Presenting Situation

The client appears to be timid since he does not open up right away. He is the youngest sibling of the family. He seems to be under pressure because of the present situation between the eldest brother and his mother. They always disagree due to the house chores. Bo does little to help with the chores of the house and states that he does not want to be told what to do in the house. All he wants to do is sit on the couch and do nothing since the he is a couch potato. Bo appears to be proud of his siblings accomplishments because of he keeps sharing the same spotlights. He uses barriers as his defense and knows little about his dental and mental health.

Strengths and Resources : Before we begin I would like to set the record clear that everything that you will share is private and confidential. This implies that I will not share information that affects the privacy of the client in any way.

Bo still lives at home with his mother and brother.

Bo loves his brother and he is even proud of him.

Bo’s health is not at its very best.

Bo has not attended any counseling session or peer groups at this time.

Since your position at the moment is not what you want it to be, name some things that you are good at doing to help make the situation better for you and your family. How can you bring your family together to achieve the goals that you want to achieve? What are some of the accomplishments that you would like for your family to have? If my agency would come and help you choose the right path, would you accept their services? Describe the relationship between you and your family. Describe the relationship between you and your mother. Do you have a girlfriend? Do you feel safe at home? I will have my agency make an appointment with the dentist and a doctor and get you to the appointment.

Potential Barriers:

Bo mentions that he does not want anything in the house since all he wants to do is to sit on the couch without anything that motivates him. He is the youngest of the two children and does not speak about his father. Bo speaks about his grandfather being the father figure for him. He calls his grandfather, dad. Bo has barriers that prevents him from moving forward and be as successful as he should be.

(You do not have to solve them here; just identify them. Explain to the client that their case manager will come back to these barriers when they work with the client on developing their individualized service plan.)I can see that you are a nervous because of your presence here. I will say that this is normal for everyone. What about the special summer that you have ever had since you were young and state how it made you feel. You might feel that I am prying on your privacy, but I am trying to find out a way in which I can help your family get more help to move you out of this region so that you can have an environment where you can move around with your peers. Can you share the feeling you have towards your father?

Culture and Language Considerations:

The family that Bo was born has continuously experienced poverty and they have lacked education for many years. Matt is the eldest brother in the family and turns out to be the only one to have gone to high school. His mother expects life for what it is now and does not see any need to continue with education. Tammy has neither moved up in her career nor had any raise since her hire date. The family lacks transportation and Bo has not had any medical or dental care for quite some time because he lacks medical insurance. Bo suffers from dental pain that affects him daily. He grew up without a father and lost his grandparents while he was young. The family lacks a convenient support system and Bo has substance abuse problems; considering that his biological father was an alcoholic. Bo started drinking a tender age of eleven and smoked cigarettes at the age of ten.

Current Client Involvement with Other Agencies and Services:

Assessments of Client Domains:

Family: Bolives with mother, Tammy and older brother Matt

Social: Bo does not participate in any social activities after school.

Spiritual: Bo does not go to church

Housing: Bo lives in a 3-bedroom trailer with mother and brother

Education: Bo is currently on 10th grade

Employment:Bo is not employed

Access to health and dental care: Bo should seek medical attention more often to improve his situation

Transportation: There is no transportation provided for the family other than a public transportation.

Hobbies and Recreation: Bo stated that he doe not like doing anything but he would like to play football

Other

Current Medications:

Name/Dosage: None

Side effects: No

Medication allergies: No known allergies Prescribed by: No current Medication

Safety and Trauma History:

Are you safe in your current living situation? (Yes/No) Y Do you feel threatened in any way? (Yes/No) N

If yes, please describe: Bo stated that he feels safe at home with his mother and brother.

Are you now, or have you in the past, experienced trauma of any kind? (Yes/No) If yes, indicate all that apply:

Emotiona: Bo seems vary nervous and timid Sexual: None

Physical:He seems to be nervous and avoids eye contact.

Provide a brief description of this and your present status. Include a brief statement of any previous treatments or services you have received for this trauma(s) and whether or not you have any remaining symptoms or issues you would like help with.

There are no previous services as stated by the client. The client has, however, future appointments set up for dental, health, and counseling.

If applicable, do you have a safety plan? (Yes/No) NO

Do you need immediate help today to gain safety? (Yes/No) NO

Client’s Legal History: No legal history noted

Suicide/Homicide Risk Evaluation: (For each of the following, use the scale: 1-None, 2 – Slight, 3 –

Moderate, 4 - Extreme/Immediate) 1

Client’s self-rating of suicide risk: (Indicate 1, 2, 3, or 4) 1 Client’s self-rating of becoming violent: (Indicate 1, 2, 3, or 4) 2

Client’s self-rating of homicide risk: (Indicate 1, 2, 3, or 4)1

Self-harm Risk Evaluation: (1-Never, 2 – Once, 3 – Occasionally, 4 - Frequently)1

Have you ever cut yourself or purposely injured yourself in any way? (1-Never, 2 – Once, 3 –

Occasionally, 4 - Frequently)1

Safety Plan Based on Client Risk Self-Assessment: Bo stated that he has never caused harm to self or others. He does not have any suicidal intention. Bo stated that he does not feel bad when his brother fails to acknowledge him in public.

Client Status (caseworker observation of client report)

Appearance:

Age appropriate (Yes/No) yes

Well groomed (Yes/No) no Disheveled/unkempt (Yes/No) no

Other – explain (Yes/No) yes

Orientation (Is client aware of the following?): Where they are (Yes/No) yes

Why they are here (Yes/No) yes Day and time (Yes/No) yes

Their situation (Yes/No) Yes

Current events (Yes/No) Yes

Behavior/Body Language: Open (Yes/No) yes Good (Yes/No) yes Limited (Yes/No) no Avoidant (Yes/No) no None (Yes/No) yes

Relaxed/calm (Yes/No) no Restless (Yes/No) no

Rigid (Yes/No) no

Agitated (Yes/No) yes Slumped posture (Yes/No) yes Tense (Yes/No) yes

Tics (Yes/No) no Tremors (Yes/No) yes Other – explain

Motor Activity:

Full ability (Yes/No) yes

Minor impairment (Yes/No) no Serious impairment (Yes/No) no Catatonic behavior other – explain

Manner:

Friendly (Yes/No) yes Trusting (Yes/No) yes Cooperative (Yes/No) no Nervous (Yes/No) yes Withdrawn (Yes/No) yes

Speech:

Mood:

Playful (Yes/No) no Evasive (Yes/No) no Guarded (Yes/No) yes Quiet (Yes/No) yes Passive (Yes/No) yes Defensive (Yes/No) yes

Hostile (Yes/No) no Agitated (Yes/No) yes Demanding Yes/No) no

Clear (Yes/No) no Understandable (Yes/No) yes Incoherent (Yes/No) yes Rapid (Yes/No) no

Quiet (Yes/No) yes Loud (Yes/No) no Slurred (Yes/No) no Slow (Yes/No) no

Appropriate (considering presenting situation) (Yes/No) no Depressed (Yes/No) no

Irritable (Yes/No) yes Anxious (Yes/No) no Euphoric (Yes/No) no Fatigued (Yes/No) yes Angry (Yes/No) yes Expansive (Yes/No) no

Unable to evaluate – explain (Yes/No) no

Affect:

Sleep:

Appropriate (considering presenting situation) (Yes/No) yes Warm (Yes/No) yes

Welcoming (Yes/No) no Tearful (Yes/No) yes Blunted (Yes/No) no Constricted (Yes/No) yes Flat (Yes/No) no

Labile (Yes/No) no Excited (Yes/No) no Anhedonic (Yes/No) no

Excellent (Yes/No) yes Good (Yes/No) yes

Fair (Yes/No) no

Poor (Yes/No) no Increased (Yes/No) yes Decreased (Yes/No) no

Initial insomnia (Yes/No) no Middle insomnia (Yes/No) no Terminal insomnia (Yes/No) no

Client reports concern about sleep pattern (Yes/No) no

Appetite:

Excellent (Yes/No) yes Good (Yes/No) yes

Fair (Yes/No) no

Poor (Yes/No) no Increased (Yes/No) no

Decreased (Yes/No)no

Weight gain (Yes/No)no

Weight loss (Yes/No)no

Client reports concern about appetite or weight (Yes/No)no

Thought Process:

Logical and well organized (Yes/No) no Illogical (Yes/No) yes

Flight of ideas (Yes/No) no Circumstantial (Yes/No) no Loose associations (Yes/No) no

Rambling (Yes/No) yes Obsessive (Yes/No) no Blocking (Yes/No) yes Tangential (Yes/No) yes Spontaneous (Yes/No) no Perseverative (Yes/No) no Distractible (Yes/No) no

Thought Content:

Appropriate (considering presenting situation) (Yes/No) yes Delusions (Yes/No) no

Paranoid delusions (Yes/No) no Distortions (Yes/No) yes

Thought withdrawal (Yes/No) yes Thought insertion (Yes/No) yes Thought broadcast (Yes/No) no Magical thinking (Yes/No) no Somatic delusions (Yes/No) none

Ideas of reference (Yes/No) none

Delusional guilt (Yes/No) none

Grandiose delusions (Yes/No) none

Nihilistic delusions (Yes/No) none

Ideas of inference (Yes/No) none

Unable to evaluate – explain

Perceptions:

Appropriate (considering presenting situation) (Yes/No) none Illusions (Yes/No) none

Hallucinations (Yes/No) none Depersonalization (Yes/No)none Derealization (Yes/No) none

Unable to evaluate – explain (Yes/No) none Judgment:

Intact (Yes/No) no

Age appropriate (Yes/No) yes Impulsive (Yes/No) no Immature (Yes/No) yes Impaired (Yes/No) no

Mild (Yes/No) no

Unable to evaluate – explain (Yes/No) no Client reports (Yes/No) no

Insight:

Intact (Yes/No) yes Limited (Yes/No) no

Very limited (Yes/No) no Fair (Yes/No) no

None (Yes/No) no

Aware of current situation (Yes/No) yes

Understands internal and external factors involved in current situation (Yes/No)yes

Unable to evaluate – explain (Yes/No)

Client reports (Yes/No)yes

Memory:

Intact (Yes/No) yes

Impaired (Yes/No) no Immediate recall (Yes/No) yes Remote (Yes/No) no

Unable to evaluate – explain (Yes/No)

Amnesia (Yes/No) no (type of amnesia) Cognitive functioning:

No issues noted (Yes/No) no

Issues noted – describe (Yes/No) no Client reports (Yes/No) no

Substance Use/Abuse:

Experiencing:

Withdrawal (Yes/No) no Blackouts (Yes/No) no Hallucinations (Yes/No) no Vomiting (Yes/No) no

Severe depression (Yes/No) no

DTs and shaking (Yes/No) yes

Seizures (Yes/No)no

Other (Yes/No)

If yes, describe:

Patterns of Use:

Do you use more under stress? (Yes/No) no

Do you continue to use when others have stopped? (Yes/No) yes

Have you lied about consumption? (Yes/No) yes

Have you tried to avoid others while using? (Yes/No) no

Have you been drunk/high for several days at a time? (Yes/No) yes

Do you sometimes neglect obligations when using? (Yes/No) yes

Do you sometimes use more than you intended? (Yes/No) yes

Are you finding you need to increase use to get the effect you desire? (Yes/No) yes

Have you tried to hide consumption? (Yes/No) yes

Do you sometimes use before noon? (Yes/No) yes

Do you find you cannot limit use once begun? (Yes/No) yes

Have you failed to keep promises to reduce use? (Yes/No) yes

Do you arrange your day around your substance use? (Yes/No) yes

Have you attempted to reduce or stop before? (Yes/No) no

What happened?

Describe the circumstances that usually lead to a relapse for you: According to BBo, after having a bad day of drinking and smoking, he usually goes through a rough stage from detox and he has to take another drink and smoke in order to evade the pain.

Do you want to reduce or stop using the substances described above? (Yes/No) yes

Do you have depression or other mental health issues that you believe affect your use of substances?

(Yes/No) no

If yes, please describe:

Are you presently involved in AA/NA? (Yes/No) no

What are your goals for change in this area?

The goals that Bo gave are to stop drinking and smoking. Although Tammy feels that Bo will not make it to highschool, he plans to go back to school so that he will get a chance to graduate and secure himself a job.

DSM 5 Diagnostic Impression (Diagnostic Impression means an interpretive statement based upon previous and current evaluative data. A diagnostic impression may or may not make reference to DSM criteria):

Clinical Summary: (Using the information you have gathered at this point, provide a brief summary of the presenting issues, client strengths and needs, any immediate risks, and the client’s goals for change. You will be reviewing this assessment and your summary and recommendations with the client and with your clinical supervisor so be sure to write in terms the client can understand and relate to (avoid technical jargon) and maintain a strength-based and empowerment perspective.)

The clients mother displays a great concern for him and the future of his education. His mother is worried about his smoking and drinking. Bo stated that he was aware that his sessions were confidential, thus will not be shared with anyone. The client will have arranged appointments so that he can visit a local resource group in the community for further evaluation.

Recommendations: (including specific service recommendations) Bo will have to visit a dentist, physician, counselor, and a case manager for a review of his situation .

Disposition: (clearly describe the next steps and what this client can expect next from your agency. If you have already arranged an intake with a case manager or a counselor, include the name of the worker, their credentials, and the date and time of the next appointment.)

Bo is among the school drop outs who have engaged in substance abuse. His mother Tammy is worried about his drinking and smoking as well as his drop from school. Bo appears to be very emotional when speaking about his grandfather who turns out to be his father figure. He succumbed to lung cancer. Bo will have an assigned case manager as well as a peer counselor to help with the current situation that he is.

Client Signature: Bo Crabtree

Date:26/06/2017

Legal Guardian’s Signature (if one is assigned or if client is under 18): Taby Crabtree

Date:24/06/2017

Case Manager Signature: Date :

Grading Rubric Unit 6 Assignment