SOARS WORKS MSR

Medical Summary Report Template

Use your own agency letterhead and delete the guidance underneath each heading when submitting to DDS.

Mr. Will Jones

XYZ Community MHC

Fax: (111) 222-4444

Collette Marie Rose

SSN: 999-99-9999

DOB: 12-04-1988

Dear DDS Examiner,

I first met Colette Marie Rose on 2/22/22 at the 5th and Main Day center. Colette is a 33 year old Caucasian woman, around 5’3 and approximately 160 lbs. Colette has brown hair, and brown eyes. At this time she appeared to be sad, or depressed and looked as if she had been crying. Colette’s face was also red, and tear stained and did not seem to have on any makeup. Colette’s clothing was appropriate for the weather, but her clothing seemed to be wrinkled, and dirty. It was at this time that Colette stated that was her first time at the center, and that she was not receiving any services in the community. Colette reported that she has been bouncing around living situations her whole life and is currently living out of her car. She also stated that she sometimes stays with her half sister, but never for more than a few nights. Colette displayed a feeling of hopelessness and talked about things never getting better. She also stated that her 3 year old daughter Layla was in Child Protective Services and had been in their custody for almost a year. I asked Colette had she applied for SSI/SSDI and she said she didn’t believe that she qualified for them. When asked why did she feel that way Colette began to cry and stated because she had been arrested in the past. I then reassured her that having a legal history would not disqualify her, and I gave her a brief overview of the application process. She then agreed to meet me that Friday to discuss starting the SSI/SSDI application. I tried to get her contact information but she did not have a phone and was reluctant to tell me where she parked her car at night. My next encounter with Colette was on 3/19/2022 on the street outside of 5th and Main Day Center. Colette appeared to have good hygiene and was wearing a dress shirt, and pants. Her hair was styled, and she was wearing blue eye shadow and pink lipstick. I asked Colette had she given any thought to working on her SSI/SSDI application. At this time Colette stated that she no longer needed disability. During this conversation Colette displayed delusions of grandeur, as evidenced by plans to publish a book that would sell millions of copies and then taking her daughter (who is not currently in her custody) to Europe. During this time Colette spoke rapidly, with tangential thought pattern and flight of ideas, she repeatedly asked me if I had been on an airplane. She also rapidly, repeated questions to me without waiting on my response, and then she suddenly ended the conversation by exclaiming in an exaggerated manner, that she had to go and then she ran across the street. During this time I believe she was in a state of mania. I next received a referral from the social worker at Any County Jail, Mental Health Services on 5/14/22. The referral stated that Colette had been incarecerated since 4/1/22 and that she would be released on 6/1/22 and the social worker wanted us to assist Colette with SSi/SSDI benefits. On 5/15/22 at the County Jail, I was able to meet with Collette. Her demeanor was uninteresting and she gave off the impression of being miserable. Saying are you ready to hear about my failing life, is how Ms. Collette Rose began the discussion. Due to the fact that she spoke slowly and frequently required prompting to return to the subject at hand, she asserted that she was unable to recall what she was discussing. Collette gave off the impression of being depressed throughout the entire chat, and she frequently closed her eyes or made terrible eye contact. Colette stead that she did not remember me although we had met on two separate occasions. Colette also reported that she was experiencing difficulty sleeping, and that she only sleeps a few hours in the daytime, but never at night. At this time she stated that she slept in her car, but often walked around until 3am because she couldn’t sleep. When I asked her about this she became very angry, and said that her life was none of my business. Colette expressed agitation when talking about her family and requested that we end the interview. When it comes to the application for Social Security that Collette Marie Rose has submitted, I am writing on her behalf. My name is Will Jones and I am her SOARS case worker.

As far as I've been able to gather, Collette's life has not been very stable. I had help with these finding upon speaking with her half sister Stephanie Montaine. Due to the fact that Collette's father John Rose abandoned her family when she was a young child appears to have had a significant impact on her and her development. Since her father had passed away, her mother Mary Moore was in need of assistance, and as a result, she allow men to enter and exit the family home. Collette had no choice but to witness the men assaulting her mother. The phrase "run and hide" is something that Colette says she learned how to do at a young age when she had no one there to protect her. An excessive amount of alcohol was consumed by Collette's mother due to the stress that she experienced as a result of being abused herself. Due to the fact that Collette was the oldest child of her mother, she felt obligated to take care of her mother and provide assistance to her to the greatest extent possible. When Colette was eleven her mother married Rick. Following the birth of her three children, Collette did not experience a sense of belonging inside the family. Collette's relationship with her stepfather became severed as a result of this. The moment Collette realized that Rick liked her "a little too much," she began to develop a negative attitude toward him. According to Colette’s sister “When Collette was fifteen years old, she was placed in the care of foster parents. During this specific time, Collette's foster mother developed a strong aversion to her. Her adopted father, on the other hand, was the one who made her feels secure. When Collette's foster mother found out that her foster father and Colette had a good relationship she kicked him out of the house. Following that, Collette's foster mother began to physically abuse her. Collette was subjected to physically and sexually abusive treatment both in her own home and while she was in the care of foster parents. At that point Colette decided to run away. She was 15 years old when she was in a relationship with Tito, who had her share drugs and have sex with others. Collette was sixteen years old when she started seeing a thirty-year-old man by the name of James. Around the age of eighteen years old, she gave birth to her first child James Robert Brown, Jr., also known as "Jimmy". Colette says James seemed to have lost interest in her once her son was born. She suffered violence throughout this relationship as well, and James had broken her jaw. Following this incident, CPS became involved and removed Jimmy from Collette's care. James and her were together for about four years. Collette never had a spouse. Collette hesitated to talk about her present love relationships. She also stated that she had became depressed several times after her encounter with James and that she had also experienced several miscarriages during their time together. Collette also stated that she has had problems with her children but I was unable to get any information due to her crying, and not wanting to confide in me and tell me what actually happened. Due to her past traumas Colette has not been functioning well. She is now more depressed than ever, and seems to be self medicating. Her alcohol use is more excessive and her stress levels have been severely heightened. Colette’s trust levels are also at an all time low, and she feels hopeless. Colette has suffered from depression since early childhood, which has since progressed and she also shows signs of mania.

Educational History

She finished the eighth grade and left school in the ninth. When talking about this, she became tearful and stated, “I didn’t finish school because I don’t finish anything.” She reports that before leaving school she got A’s and B’s and that a teacher helped her manage schoolwork.

Legal History

Collette is currently incarcerated at Any County Jail on a larceny charge she was incarcerated on 4/1/22, and is expected to be released on 6/1/22. She was arrested six times prior to this. Her mental illness had her taking something that did not belong to her but in her mind, she actually thought it was hers.

Previous Incarcerations/Arrests

2011 from November 8 to December 8

December 25, 2010 – January 25, 2011

July 8–October 8, 2009

February 12–June 12, 2008

Colette was charged with two counts of driving under the influence of alcohol in 2006, and her license was revoked. After completing a six-week course, her license was issued back to her. several larceny, trespassing, and other small-time offense arrests have also been made.

Occupational History

Collette stated that she has had several jobs over the years in which none of them lasted more than 2 weeks. She said that she was told that she was too slow. Collette was unable to follow instructions in order to maintain employment.  Collette held positions at a convenience store in April 2010, a "burger joint"(as she stated) in April 2010, and Bandito Burrito in March 2011, Bandito Burrito was the only place of employment that she remembered the name of. She was not employed prior to this she received help from family, or the partners she was with at the time. Her most recent job was working two weeks in December 2011 as a shelf stocker at Q-Mart; she last worked there on December 21, 2011. Colette had resigned from her fast-food job when she was required to use a computer, demonstrating her inability to hold down a job and complete tasks. Colette also stated that she had been yelled at by her supervisors for being very slow at completing tasks. She also stated that while working at her grocery store position, she initially completed tasks rather quickly but received criticism for organizing items using her own method. Collette continued to cry during the extent of the conversation regarding her employment history.

Physical Health Treatment

According to Collette’s medical report she suffers from high blood pressure, as well as diabetes. Collette has been known to drink so much that she blacks out and is taken to the emergency room due to these health issues. Colette is inconsistent in taking medication and does not follow her prescribed diet.

Mental Health Treatment

Collette has a known history of bipolar, and depression. She is currently experiencing severe symptoms of depression. She has no energy and cannot properly care for her basic personal hygiene or other needs. She will sleep most of the day and will only interact for a few minutes at a time before getting too tired. Collette will often cry while speaking about her past. Several months ago, she was seen experiencing a manic episode. Collette was first diagnosed with depression in 2001 in the emergency department at County General. She has received sporadic treatment for depression and bi-polar disorder at County General as well as, the County Jail. She has taken medication for short periods of time but has never followed up with outpatient treatment. At the County General Hospital, she was prescribed Seroquel, Lamictal, Prozac, and lithium. Her ongoing medications if taken are Amitriptyline 50mg po qhs and is set to begin Lamotrigine 300mg po qhs. Below is a brief history of her psychiatric and psychological treatments.

PSYCHIATRIC/PSYCHOLOGICAL HISTORY

2011 March 20-23 Inpatient Psychiatric

2010 April 15-22 Inpatient Psychiatric

2007 August 1-3 Inpatient Psychiatric

2007 Jan 1-3 Inpatient Psychiatric

2006 June 15-18 Inpatient Psychiatric

2005 Feb 14-28 Inpatient Psychiatric

2004 Sept 1-4 Inpatient Psychiatric

2003 Dec 26-29 Inpatient Psychiatric

2001 Nov 6-10 Inpatient Psychiatric

2000 Mar 16-19 Inpatient Psychiatric

1997 Feb 14-17 Inpatient Psychiatric

1995 June 5-3 Inpatient Psychiatric

1991 May 6-10 Inpatient Psychiatric

As seen above, Colette has a lengthy history of psychiatric issues.

Substance Use

Colette has been attending the County Probation Alternatives Program and is currently sober. She’s been sober for nine weeks right now. According to Colette’s evaluation by Dr. Banes at XYZ CMHC Colette has a recent, and a past history of drug and alcohol abuse. Previously used cocaine and alcohol but have had "extreme experimentation" with various substances and claims to have used "anything that will numb the pain." Says she was sober both during Layla's pregnancy and on probation. She continued to suffer with depression during these periods of sobriety and also had manic episodes while sober. Dr. Banes further stated that Colette has had inpatient treatment but continues use when she has access to alcohol. Colette reported to Dr. Banes that her alcohol use helps her to deal with day-to-day life. She

Functional Information

Ms. Collete Rose shows considerable deficits in all spheres of functioning due to the symptoms of her mental illness, including bipolar, major depressive disorder, and disorganized cognitive patterns; this has helped to explain her incapacity to engage in daily activities or sustain work. The talk with Ms. Rose is unclear and challenging to follow. Because of the symptoms of her mental illness, Ms. Colette frequently misinterprets factual information, which leads to recurrent missed appointments and a loss of communication with doctors. She was fired from previous employers, for instance, because she couldn't follow straightforward directions. She can't take her medication correctly and can't take it as directed. Ms. Rose struggles to recall important details and information because of her disorganized and hallucinatory thinking.

Understand, Remember, or Apply Information

Collette’s speech is unclear and challenging to grasp because of tangential and misled mental processes. Because of the symptoms of her mental illness, Collette regularly misunderstands true information, which leads to missed visits and lost relationship with doctors. She was fired, for instance, because she is unable to follow basic directions.

Interact with Others

It is evident from observation that Ms. Rose withdraws socially and only communicates with her sister rather than the rest of her family. When discussing her experiences, she becomes readily sidetracked and easily overwhelmed. Ms. Colette has a habit of isolating herself and avoiding people in public. There is no one who likes her. Although it is simpler to be alone and stay out of trouble, I want someone to love me. Collette claims that in order for her partner to know where to locate her, she spent practically all of her time alone in his apartment during their previous relationship. Ms. Rose experiences significant difficulty interacting with others in daily life due to her issues with consistency, realism, and concentration.

Concentrate, Persist, or Maintain Pace

For Collette, who is considerably more sensitive, the need to focus and sustain attention is null. This makes it quite difficult for her to do tasks. As a result, there is no demand for concentration or attention maintenance. Ms. Rose's inability to follow instructions and accomplish tasks has already cost her multiple jobs. She was fired as a result of repeated complaints from her coworkers that she worked more slowly than her other co-workers. Ms. Benedetto stated that Collette worked alone at night stacking shelves. She claimed that Collette was often correcting her work and that she needed directions on how to do tasks reiterated to her. Collette initially worked quickly, but Ms. Benedetto claims that she put items in the incorrect area of the store. "Collette claimed to have had her own particular style of doing things and grew enraged when she was urged to follow the directions Ms. Benedetto provided. No matter how gently she was corrected Colette would cry uncontrollably. She would not stop crying, so Ms. Benedetto had to send her home quite a bit. Ms. Benedetto realized after the third time that she was unable to function in a formal environment and was forced to terminate Colette.

Adapt or Manage Oneself

The last time this worker saw Collette free, she was erratic talking about sending her daughter on a vacation to Europe and that she wouldn't need Social Security a few days later she was imprisoned in the County Jail. Collette is unable to care for herself. She sleeps for most of the day. She usually tears when she talks about her family history and only talks for a few minutes at a time before becoming very exhausted. Three months ago, she was seen having a manic episode. She showed pressed speech, had great ideas, changed her goal-directed conduct, and became more distractible. Ms. Rose is unable to care for herself. Collette has never paid bills or kept up a house before. She says she gets lost and that's why she can’t ride the bus. She drives, but the car is unregistered and she is not covered by insurance, so she mostly just uses the vehicle as a place to sleep.

Summary

Colette a 33 years old, white, and single female. She has two kids that she does not have in her custody at this time. Colette has been identified with Major Depressive Disorder, Bipolar Disorder, High Blood Pressure, and Diabetes that are not being managed or medicated properly. Ms. Rose is currently homeless and doesn't have a fixed place to go when she gets out of jail. Because of the symptoms of her mental illness, she did things that were against the law. Colette hasn't been able to keep up good, stable relationships because she hasn't been able to do her own daily ADLs or those of her children. Due to her mental illness and functional impairments, Colette has not been able to work at a substantial earning level. Colette can not maintain a job due to her physically not being able to stay awake, and live a health lifestyle.

If you have any questions, please call Will Jones at 111-222-3333,

Sincerely,

Will Jones

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