Case Management Assessment
National University PSY 610 Case Management
Jane Smith is a female Caucasian who was born July 19, 1990, she is currently 24 years old. The assessment was taken on December 12, 2014. There seems to be a few presenting problem at this time. Client stays at home most days, except for when she needs to buy food and alcohol and goes on one mile walk 4-5 times a week. Client stated she drinks a six pack of beer each day starting when she wakes up in the morning around 10:00am. Client stated she was divorced about 8 months ago to her husband of one year. Client feel sad and depressed since her divorce which caused her to start drinking alcohol regularly. She feels sad and lonely from her circumstance. Client’s ex-husband paid for everything in her life since they dated when she was 16 years old. She feels helpless and has low self-esteem. Client needs assistance to help her with low income housing and welfare. She thinks if her life circumstances (income, housing) improves she will feel much better about herself. Client thinks that alcohol will not be a problem if she can get support. Current Client Involvement with other Agencies
Client denies any involvement with other agencies
Assessment of Life Circumstances or Changes in the Following Areas: Family
Client is not involved with any other agencies. Client never met her father and her mother died when she was 14 years old. Client is the second youngest of 8 children. She has not spoken to any of her siblings in 4 years and last she heard, all of them had substance abuse problem. Social
Client has a boyfriend who she sees once a week or less. Although she has a boyfriend, he is not around much and their relationship is “fading away”. Client does not have any friends. Her only friend was her husband but he is not in her life anymore, then she got a boyfriend and he is not very involved in her life. Support
Client says she has no support.
Client received $10,000 in her divorce, other than her divorce, the client has had no legal issues. Education
Client graduated from High School and never attended college. Occupation
Client currently has no job but worked at McDonalds for 2 months after she graduated. Finances
Client received $10,000 from the divorce and she has $1,500 left. Client said she was spending the money fast and needs help. Psychosocial and Environment Problems
Client has no support, no job and not much money. She is feeling depressed from her circumstance which mainly started from being on her own after she was divorced 8 months ago. The client recognizes she has a problem with alcohol and wants to change. Current Medical Condition
Client denies having any medical conditions.
Primary Care Physician
Client denies having a primary care physician
Client denies having any medications
Relationship Risk Factor
Client reported feeling safe and denies feeling threatened at home, she denies being abused in any way in any relationship, and no legal action has taken place. Suicide/Homicide Evaluation
Client reported as being non-suicidal and non-violent.
Mental Status Exam
Client appeared age appropriate, she knew who she was, what day it was and where she was. Her eye contact was good, her motor activity and mannerisms appeared normal and appropriate. She seemed a little guarded at the beginning of our visit but was much more comfortable towards the end of our visit. Her speech was normal, her mood seemed appropriate and urgent for change. Client sleeps well most nights and her appetite seems to be fair to good. Clients thought process was logical and well organized and appeared to have no delusions. She reported no suicide or violence risk. Client’s judgment appeared to be age appropriate and her insight appeared to be intact. She seemed to be alert and attentive and her memory seemed to be intact. She seemed to show...
Please join StudyMode to read the full document