HN330 Unit 9 Assignment

Client Name: Bo Crabtree

Date of Birth: 1/18/2004

Date of Assessment: 9/30/2017

Presenting Situation Bo is a 13 year old boy who is requesting assistance, accompianed by his mother, Tammy. Bo is in immediate need of health services, specifically dental care. He is at severe risk of failing his current grade in school because he is not attending classes; he may have learning dissabilities but according to Tammy has never been tested. Bo reports that he wants to make it to high school.

Strengths and Resources: Bo desires to be more successful than his family has been in the past. He wants to make it to high school, and graduate. He has one good friend who provides support, but also encourages Bo to use cigarettes and alcohol. Bo’s mother, Tammy, is supportive of her children but does not have the means to help them be more successful due to living in poverty. Bo looks up to his brother, who is the first person in the family to make it to high school. Bo can attend school, but chooses not to because he has been the victim of bullying. Tammy works hard, and has set the example that Bo should work instead of living from government assistance.

Potential Barriers: Bo’s dental problems cause him constant pain, which he alleviates with alcohol. He is bullied in school, which causes him to not attend. Bo’s mother is unable to provide adequate living conditions. Example: no furnace to provide heat in winter months, and no car to make grocery trips or other necessary errands. Bo is embarrassed about the clothes he wears. He lacks a support system with many good role models.

Culture and Language Considerations: Bo and Tammy do not mention cultural considerations. Bo does mention that he enjoyed attending church, but does not mention a specific religion. Tammy mentions that Bo may have a learning disability, but he has not been tested.

Current Client Involvement with Other Agencies and Services:

Assessments of Client Domains:

Family: Bo lives with his mother, Tammy, and older brother, Matt. His father and grandparents are deceased.

Social: Bo has one close friend, no name mentioned, who lives close to him. They spend most days together. He mentions he is bullied by other students.

Spiritual: He mentions attending church as child, no specific religion. He has not attended in several years.

Housing: Bo lives in a trailer that is in poor shape with his mother and brother. The home has many issues, and needs many repairs.

Education: Bo is currently attending middle school, but his attendance is poor.

Employment: Bo is not employed.

Access to health and dental care: Bo has limited to no access to health and dental care because he does not have health insurance.

Transportation: Bo’s mother, Tammy, does not have a working vehicle. Bo has access to a school bus.

Hobbies and recreation: Bo’s enjoys playing video games, and being outdoors.

Other: Bo is currently using alcohol and cigarettes almost daily, but does not desire to quit.

Current Medications:

Name/Dosage: No medications mentioned

Side effects:

Medication allergies: Non

Prescribed by:

Safety and Trauma History:

Are you safe in your current living situation? (Yes/No) _Yes_

Do you feel threatened in any way? (Yes/No) _No_

If yes, please describe:

Are you now, or have you in the past, experienced trauma of any kind? (Yes/No) Yes_

If yes, indicate all that apply:

Emotional: Grandparents passing when he was young; seeing his father abuse his mother

Sexual:

Physical:

Provide a brief description of this and your present status. Bo does not state needing further treatment for any trauma.

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:

Suicide/Homicide Risk Evaluation: (For each of the following, use the scale: 1-None, 2 – Slight, 3 – Moderate, 4 - Extreme/Immediate)

Client’s self-rating of suicide risk: 1

Client’s self-rating of becoming violent: 1

Client’s self-rating of homicide risk: 1

Self-harm Risk Evaluation: 1

Have you ever cut yourself or purposely injured yourself in any way? 1

Safety Plan Based on Client Risk Self-Assessment: N/A

Client Status (caseworker observation of client report)

Appearance:

Age appropriate (Yes/No) Yes

Well groomed (Yes/No) Yes

Disheveled/unkempt (Yes/No) No

Other

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) No

Relaxed/calm (Yes/No) Yes

Restless (Yes/No) No

Rigid (Yes/No) No

Agitated (Yes/No) No

Slumped posture (Yes/No) No

Tense (Yes/No) No

Tics (Yes/No) No

Tremors (Yes/No) No

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) No

Cooperative (Yes/No) __Yes____

Nervous (Yes/No) No

Withdrawn (Yes/No) No

Playful (Yes/No) No

Evasive (Yes/No) No

Guarded (Yes/No) No

Quiet (Yes/No) No

Passive (Yes/No) No

Defensive (Yes/No) No

Hostile (Yes/No) No

Agitated (Yes/No) No

Demanding (Yes/No) No

Speech:

Clear (Yes/No) __Yes

Understandable (Yes/No) __Yes_

Incoherent (Yes/No) No

Rapid (Yes/No) No

Quiet (Yes/No) No

Loud (Yes/No) No

Slurred (Yes/No) No

Slow (Yes/No) No

Mood:

Appropriate (considering presenting situation) (Yes/No) __Yes____

Depressed (Yes/No) No

Irritable (Yes/No) No

Anxious (Yes/No) No

Euphoric (Yes/No) No

Fatigued (Yes/No) No

Angry (Yes/No) No

Expansive (Yes/No) No

Unable to evaluate – explain (Yes/No) No

Affect:

Appropriate (considering presenting situation) (Yes/No) __Yes____

Warm (Yes/No) No

Welcoming (Yes/No) No

Tearful (Yes/No) No

Blunted (Yes/No) No

Constricted (Yes/No) No

Flat (Yes/No) No

Labile (Yes/No) No

Excited (Yes/No) No

Anhedonia (Yes/No) No

Sleep:

Excellent (Yes/No) No

Good (Yes/No) Yes

Fair (Yes/No) No

Poor (Yes/No) No

Increased (Yes/No) No

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) No

Good (Yes/No) No

Fair (Yes/No) Yes

Poor (Yes/No) No

Increased (Yes/No) No

Decreased (Yes/No) Yes

Weight gain (Yes/No) No

Weight loss (Yes/No) Yes

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

Thought Process:

Logical and well organized (Yes/No) __Yes____

Illogical (Yes/No) No

Flight of ideas (Yes/No) No

Circumstantial (Yes/No) No

Loose associations (Yes/No) No

Rambling (Yes/No) No

Obsessive (Yes/No) No

Blocking (Yes/No) No

Tangential (Yes/No) No

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) No

Thought withdrawal (Yes/No) No

Thought insertion (Yes/No) No

Thought broadcast (Yes/No) No

Magical thinking (Yes/No) No

Somatic delusions (Yes/No) No

Ideas of reference (Yes/No) No

Delusional guilt (Yes/No) No

Grandiose delusions (Yes/No) No

Nihilistic delusions (Yes/No) No

Ideas of inference (Yes/No) No

Unable to evaluate – N/A

Perceptions:

Appropriate (considering presenting situation) (Yes/No) __Yes____

Illusions (Yes/No) No

Hallucinations (Yes/No) No

Depersonalization (Yes/No) No

Derealization (Yes/No) No

Unable to evaluate – explain (Yes/No) No

Judgment:

Intact (Yes/No) __Yes____

Age appropriate (Yes/No) __Yes____

Impulsive (Yes/No) No

Immature (Yes/No) No

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) No

Unable to evaluate – explain (Yes/No) No

Client reports (Yes/No) No

Memory:

Intact (Yes/No) __Yes____

Impaired (Yes/No) No

Immediate recall (Yes/No) No

Remote (Yes/No) No

Unable to evaluate – explain (Yes/No) No

Amnesia (Yes/No) No (type of amnesia) ___________

Cognitive functioning:

No issues noted (Yes/No) No

Issues noted – describe (Yes/No) __Yes_ - Potential learning disability; reported by mother

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) Yes

DTs and shaking (Yes/No) No

Seizures (Yes/No) No

Other (Yes/No) No

If yes, describe:

Patterns of Use:

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

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) No

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) No

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

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

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

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

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

What happened?

Describe the circumstances that usually lead to a relapse for you:

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

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?

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

Anxiety – Depression

Clinical Summary: Bo is a 13-year-old boy who presents with poor self-esteem due to circumstances out of his control. He is in immediate need of dental care, and general healthcare. He is participating in risk-taking behaviors such as smoking cigarettes and consuming alcohol; and has no desire to stop. These risk-taking behaviors are preventing him from attending school on multiple occasions. He resides with his mother and older brother; his father is deceased. Bo may have a learning disability. He desires to continue in school, and move to high school; but has already failed two grades. Bo has been a victim of bullying by other students due to the condition of his home, and his clothing. He states that he uses alcohol to “make life easier”, and to take away the pain caused by poor dental health. Bo possesses the desire to make his life better, but needs guidance on how to accomplish this goal.

Recommendations: (including specific service recommendations)

Bo should be tested for a learning disability. I recommend meeting with the school guidance counselor to discuss testing options. I also recommend speaking with the guidance counselor about the bullying situation Bo is facing, and measures that can be taken to prevent it. Next, Bo and Tammy would benefit from applying for government health insurance. I would aid in finding an expert in health insurance benefits to guide them in this area. Bo should consider speaking with a counselor regarding his substance use, and how it is like his father’s substance abuse and the risks associated.

Disposition: Meeting with school guidance counselor for Bo and Tammy scheduled for 4/28/2017 at 9:00 a.m.

Education evaluation scheduled with school guidance counselor scheduled for 4/28/2017 at 10:45 a.m.

Benefit assistance meeting scheduled with Affordable Care Act assistance specialist scheduled for 5/1/2017 at 11:30 a.m.; Tammy will attend on behalf of Bo

Client Signature: [Bo Crabtree]

Date: 9/30/2017

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

Date: 9/30/2017

Case Manager Signature: [Tammy L. Egan]

Date: 9/30/2017

________________________________________