Wildwood Case Management Unit
Wildwood Case Management Unit
Discharge Summary
Name Belinda Avery
Date of Birth 10/23/97
Date of Admission 7/23/2015
Date of Discharge 8/16/2015
DIAGNOSIS ON ADMISSION:
Axis I V71.09
Axis II V71.09
Axis III V71.09
Axis IV V71.09
Axis V V71.09
MEDICATION:
N/A
REASON FOR DISCHARGE:
Belinda has successfully attained her GED, has attained housing through housing assistance, and has received medical assistance for her child. Belinda has worked hard to gain a job and now has acceptable identification.
PRESENTING PROBLEM:
Client is believed to be 8.5 months pregnant and is not receving prenatal care. Client has a child that is 16 months old which was delivered through a C-section. Client is currently unemployed, has not been able to pay her rent and has no transportation. Client is an American Indian and her only form of identification is her Certificate of Degree of Indian Blood (CDIB). Additionally, client does not have her birth certificate, social security, and driver license. Client has an Eighth grade education.
From SUMMERS. Fundamentals of Case Management Practice, 4E. © 2012 Wadsworth, a part of Cengage
Learning, Inc. Reproduced by permission. www.cengage.com/permissions
1
GOALS:
Gain Employment, Acquire appropriate Identification (Driver's License, Social Security Card), Attain
GED, Attain Housing/Living Arrangement, attain Medical support for her unborn child, and reliable transportation. PROGRESS:
Belinda has made progress in all of her goals except attaining transportation. Belinda attends all appointments. She has gotten a job and has recently given birth to her new baby.
ADDITIONAL ISSUES NOT ADDRESSED:
Belinda still needs child care for her two children.
IMPRESSIONS AND RECOMMENDATIONS:
Belinda should be referred to a child care assistance agency.
PREPARED BY:
Jeffrey T Green
CASE MANAGER
Jeffrey T Green
From SUMMERS. Fundamentals of Case Management Practice, 4E. © 2012 Wadsworth, a part of Cengage
Learning, Inc. Reproduced by permission.
Discharge Summary
Name Belinda Avery
Date of Birth 10/23/97
Date of Admission 7/23/2015
Date of Discharge 8/16/2015
DIAGNOSIS ON ADMISSION:
Axis I V71.09
Axis II V71.09
Axis III V71.09
Axis IV V71.09
Axis V V71.09
MEDICATION:
N/A
REASON FOR DISCHARGE:
Belinda has successfully attained her GED, has attained housing through housing assistance, and has received medical assistance for her child. Belinda has worked hard to gain a job and now has acceptable identification.
PRESENTING PROBLEM:
Client is believed to be 8.5 months pregnant and is not receving prenatal care. Client has a child that is 16 months old which was delivered through a C-section. Client is currently unemployed, has not been able to pay her rent and has no transportation. Client is an American Indian and her only form of identification is her Certificate of Degree of Indian Blood (CDIB). Additionally, client does not have her birth certificate, social security, and driver license. Client has an Eighth grade education.
From SUMMERS. Fundamentals of Case Management Practice, 4E. © 2012 Wadsworth, a part of Cengage
Learning, Inc. Reproduced by permission. www.cengage.com/permissions
1
GOALS:
Gain Employment, Acquire appropriate Identification (Driver's License, Social Security Card), Attain
GED, Attain Housing/Living Arrangement, attain Medical support for her unborn child, and reliable transportation. PROGRESS:
Belinda has made progress in all of her goals except attaining transportation. Belinda attends all appointments. She has gotten a job and has recently given birth to her new baby.
ADDITIONAL ISSUES NOT ADDRESSED:
Belinda still needs child care for her two children.
IMPRESSIONS AND RECOMMENDATIONS:
Belinda should be referred to a child care assistance agency.
PREPARED BY:
Jeffrey T Green
CASE MANAGER
Jeffrey T Green
From SUMMERS. Fundamentals of Case Management Practice, 4E. © 2012 Wadsworth, a part of Cengage
Learning, Inc. Reproduced by permission.