Demographics:
· Age-27
· Sex-Females
· Family available-Yes
· Family involvement-Yes
· Social network-Yes
· Income-Yes
· Housing-Yes
· Working-Yes
Presenting Problem – What brought person to agency?
Medical Status - Summary of what is known from assessment
· The physical disability or illness the client reports
low self-esteem issues
· Medical issues identified whether treated or not treated
· What specific ways it effects the client’s social and occupational functioning and activities of daily living.
· Perceived overall health status:
· Medications
Intellectual & Mental Health Status - Summary of what is known from assessment
· Mental functioning:
· Describe the client’s mental functioning.
The client’s functioning habits are up and down. Our goal is to have the client in a safe environment, we want to client to feel comfortable at all times.
· Has Mental health diagnosis been completed - results
· Cognitive functioning:
· Ability to think and reason?
· Able to participate and make decisions?
Yes the client is able to participate in the program with no issues and also at their work place. The decision making has gotten a lot better from where we started.
Social & Environmental Factors - Summary of what is known from assessment
· Open to outside help?
The client has been very open to outside help. The client’s close cousin has been willing to help more and more and they also have seen a big improvement in the past few weeks. I can see where the client loves to see when people of the family cares, it help them relax and get through the week.
· Impairment prohibits functioning?
· Supportive work environment?
· Social support:
· Neighbors? Friends? Community?
· Family support:
· What support, or help can be expected?
· Ethnic/religious affiliation:
· Membership? Help or hindrance?
Functional Status – Summary of what is known from assessment.
Specific Needs to be addressed in the care or treatment plan