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Sample of a Case Note

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This is a sample case note of a fictional woman.

 

DATA
*41 year old white female
*has a son, who is 17 not living with her, he is staying with her mother
*alcohol is her drug of choice and she began drinking at age 35 (until 41)
*august 9, 2005 attempted suicide and spent 7 days at harbor view, she went from there to
thunderbird treatment center for inpatient treatment
*not currently set up with intensive outpatient treatment
*not currently with a mental health provider
*goals: -find work
-clean and sober housing
-credit rebuilding
*no current funding or insurance


ASSESSMENT
*needs IOP
*needs mental health monitoring
*needs AA group and sponsor
*needs credit counseling


PLAN
*get credit report
*see mental health professional and get referral for mental health services
*sally to find a job and mission to assist in making the program fit her schedule
*obtain clean and sober housing
*basic services guest only


CASE NOTES
8/30/05 INITIAL MEETING/ REVIEW DATA:

* sally grew up in King County, on the east side (this is a trigger place for her)
*she is interested in the basic services program and is looking for a job
*she had a job and clean and sober housing and that fell through after she was released from
treatment
*she is going to make an appointment with mental health professional (mhp)
*she is not currently on meds
*she feels good and doesn't feel like drinking
*defined case manager role
*gave community voice mail number
*gave housing application to jubilee
*gave credit report form, may get petty cash for credit report and sally to reimburse when she
gets a paycheck
*she is interested in a scholarship with ymca, she is thinking instead of getting off work and
drinking, she could go work out instead
*talked about how the bus system works


ASSESSMENT:

*seems highly motivated to get work and housing
*she said she wants to be "a grown up" and do things for herself- it may be that her family has
taken care of her a lot in her addiction
*she said that she thinks that she was always destined to be an alcoholic, maybe family of
addictions


PLAN:

*Megan to ask about petty cash for credit report
*sally to get community voice mail
*sally to get an appointment with mhp
*sally to contact Megan if she gets a job


9/14/05 REVIEW DATA:

*taking spronalactone and clexa
*sally met with jann, the mhp
*she can't find a job
*doesn't want to go on gau but is interested in the Medicaid coupon
*went to pike market clinic for medical care
*some history on sally- she graduated from high school and went to beauty school, she describes
herself as a dry drunk (began drinking at age 35); all the men she chose were alcoholics. her
father was an alcoholic, she began drinking around the time he died- she found him dead
*she describes herself as always being depressed, she had been on paxil for a time , she said that
she has always felt out of control and life has always been a battle
*her son has been with her until her drinking got really bad, he is now and has been for the past
two years staying with her mother
*she has been in relationship with the same man on and off for the last ten years- after their last
break up she began planning her suicide.
*suicide attempt took place on July 9, 2005, she spent some time in harborview and she loved it
there, loved the treatment and the other clients; she spent a week with her brother before she got
into treatment and drank all that week
*went to treatment at thunderbird and saw that she is similar to the other people there but that
they have gone through a lot more than she had, as she put it.
*sally has gotten a cd assessment and she is interested in the extended program, she says that she
needs it and that she loves it here
*she is requesting information on a health club in the area
*she has a sponsor but does not feel like they connected

ASSESSMENT:

*sally appears bubbly and outgoing and so i think she manages her depression
well, she also mentioned that she was very glad to be around people, when she was drinking she
spent all her time alone
*she appears to be a sponge, soaking up the information in the classes and is very open to what
others think would be best for her
*she seems very interested in making her recovery a lifestyle


PLAN:

*sally to attend recovery classes
*Megan to begin intake at next review
*Megan to follow up on mental health care

9/20/05 REVIEW DATA:

*sally has not yet gone to dshs, there is a small part of her that thinks she should be
working and so she feels like she would be taking advantage of the system if she went for
assistance; i told her my only urging is that she has medical coverage for her mental and physical
health needs
*she is excited about all that she is learning in the bible and that it is applicable to her life
*things are going well with her mom and son, she is aware of codependence and is trying to keep
some appropriate distance
*her celexa is working well, much better she says than paxil she has had in the past; she is seeing
jann on Mondays and got her prescription from the nurse here; she has an appointment with pike
market clinic on 9/28/05
*told sally about how to apply for extended program and that i thought she would be a good fit


ASSESSMENT:

*sally is very excited to be sober and about her recovery, i think she will be a
great fit for the program, she is submitting to it and not fighting it as i feared she would earlier
*she does not feel confident that she would be ok if she went back to work and independence
*she is excited about being able to have a more consistent relationship with her son and that he is
supportive


PLAN:

*continue intake at next review
*sally to think about applying for the med coupon

9/27/05 REVIEW DATA:

*sally has been thinking about her future and would really like to be a tugboat cook
*she has begun to volunteer in the kitchen to learn how to be a cook
*we talked about the farestart program and I gave her a flyer, she is going to check it out and see
what the program requirements are
*sally is thinking about applying for weekend work, she is bored and would really like the
money; I told her that working does not work out well for everyone but she is welcome to look
into it
*wants to join extended program, sally is going to write her letter this next week
*she is enjoying her time with the counseling intern
*she has not been going to AA, I am to ask her next week about it and keep her accountable
*finished intake


ASSESSMENT:

* sally seems really grounded and realistic about her recovery, she understands
that she is bored and has a lot more time on her hands than she would like but also understands
that she would not be successful at being on her own at this time; i think it will be challenging
for her to get strictly weekend work but i can support employment that does not interfere with
her program
*she likes accountability and asks for it, which i think is a great sign


PLAN:

*breathalize sally this week
*sally to go to aa
*megan to ask about aa at next review
*sally to look for part time work

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