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

1 Course: HN330 Unit 9 Discharge Summary Form (To complete this form, enter data within the brackets. For questions that require a yes or no answer, input “x” by the choice answer.) Client Name: Sarah Freeman Date of Birth: 11/22/1976 Date of Admission: 5/26/2015 Date of Discharge: 6/10/2016 Reason for Discharge [If the client is transferring to case management services at another agency, in addition to the Reason for Discharge, include the new agency address and new case manager name and contact information] : Client and case manager are in agreement that the client is ready to move on. Diagnosis on Admission: Depression Medication on date of discharge and plan for continuing prescriptions: Wellbutrin. Client will continue to be monitored by her psychiatrist, Susan Davies for medication purposes. Presenting situation as described by client at admission to case management program (Should reflect the presenting situation in the Unit 6 Intake Assessment) : Sarah is a 38 year old st ay at home mom. She is requesting help for, what she believes, is “depression.” According to Sarah, she was first diagnosed with depression in 2007 after she had her first child. Sarah now has five children ranging in age from 6 months - 8 years. She st ates that the “feelings of hopelessness” have become gradually more intense with each child. She also reports that she is struggling to care for her 5 children and that she feels “extremely guilty” about that. Sarah describes her depression as an “inabil ity to engage my children throughout the day” and a “constant feeling of extreme exhaustion and hopelessness.” She also states that “I have lost interest in going out 2 and talking with friends.” According to Sarah she is here because her husband “insisted that I get help.” He expressed concern to Sarah about how her condition is affecting her, their marriage and their children. Their oldest daughter allegedly asked them what she did to “make mommy so sad.” Goals (Should reflect the goals that were created in the Unit 7 Individualized Service Plan) : 1. Sarah will find a part -time teaching assistant position by September 2015. a. Sarah will review local job listings and apply for 3 teaching assistant positions by July 15, 2015. 2. Sarah will resume attending the women’s writing group that she used to belong to. a. Sarah will call the group facilitator to see when the group is meet ing over the next few months. Sarah will attend one group before September 2015. 3. Sarah will take steps to manage her depression by August 2015 . a. Psychiatric Evaluation will occur on 6/1/2015. b. Sarah will continue to meet with her therapist one time per week. 4. Sarah will take steps to curb her alcohol intake. a. Sarah will attend her first AA meeting on 6/8/2015 and will continue to attend 1 time per week. 5. Sarah will use the Family Place to participate in support groups, parent education and playgroups. a. Sarah will call the F amily Place to requ est the summer 2015 calendar. Sarah will attend 1 activity per week starting the week of June 8 th, 2015. 6. Sarah will use her Church community to reconnect spiritually to family and friends. a. Sarah will attend church 2 times per month, sta rting the week of June 8 th, 2015. 7. Sarah will find in -home support for her 8-year -old son. a. Sarah will call her son’s school and request a referral for in -home care. 3 Progress (State goals that have been achieved as well as goals not achieved and client plan for these upon discharge): At intake, Sarah was not working and was overwhelmed by the responsibility of caring for her 5 young children. She was also struggling with depression and alcoholism. Sarah has attended 20 sessions with her psychologist, Susan Davies from June 2015 -May 2016. Sarah reports that these sessions were very helpful. She also had a psychiatric evaluation in June 2015 and has been taking Wellbutrin since then, which she tolerates well. She remains on this medication at discharg e. Sarah has been attending AA meetings one time per week since June 2015. She reports that these meetings have been extremely beneficial and that she no longer turns to alcohol to deal with her depression. She will continue to attend AA meetings one t ime per week after discharge. Sarah began teaching part -time in September 2015. She reports that it has been wonderful to return to work that she loves while at the same time getting a break from “being a mom .” She is also happy to be contributing financ ially. She hopes to have her student loan paid off within the next year. Sarah has been an active participant at the Family Place. She attends one to two times per week. She enjoys the parent support groups and the playgroups for her younger children. She reports that she has made several close friends from the support groups. Sarah has been able to set -up in home intervention and services for her eight year old son with autism. Sarah now has an advocate through the public school system and has lear ned how to navigate the special needs services through the school system. She has also learned some new techniques to help manage her son’s behaviors at home. Sarah has also been able to reach out to her community. She has become an active member at both her church, attending two to three times per month and at a women’s writing group, attending one time per month. Additional issues or concerns not documented above :None Case manager closing summary and recommendations : Sarah is a 39 year old married woman with five young children. She sought help for depression, alcohol use and general feelings of hopelessness and exhaustion. At discharge her symptoms are less acute. She remains on Wellbutrin, which she 4 tolerates wel l. She has met all of her goals. She will continue to be monitored by her psychiatrist, attend AA meetings , receive services for her son and participate in the community activities that she has “grown to love.” I have reviewed this form with my case manager, and I understand and agree with the summary and recommendations: Yes X No Client Initials: SF Legal Guardian Initials (if one is assigned or if client is under 18): I have reviewed this form with my case manager, and I wish to add the following comment to the summary and recommendations (optional): Comment: Client Initials: Legal Guardian Initials (if one is assigned or if client is under 18): Client Signature: Sarah Freeman Date: 6/10/2016 Legal Guardian Signature (if one is assigned or if client is under 18): Date: Case Manager Signature: Jennifer Hutras Date: 6/10/201 Supervisor Signature: Janelle Evans, LCSW (Licensed Clinical Social Worker Date: 6/10/2016 Copy of this completed Discharge Form received by cl ient: 5 Client Initial: SF Legal Guardian Initial (if one is assigned or if client is under 18):