Soap Note

Patient Information | NAME: | Sharon Doe | Today’s DATE: | _11__ / 29_ / 2012_ | CLIENT: | * Established Client | * New Client | GENDER: | * Male | X Female | MEDICAL RECORD #: | | Hispanic, Latino, or Spanish Origin | X Non- Hispanic | * Hispanic: (origin: ) | RACE: | * American Indian or Alaska Native | * Asian | X Black/ African American | * Native Hawaiian / Other Pacific Islander | * White / Caucasian | * Korean | | * Asian Indian | * Chinese | * Japanese | * Filipino | * Vietnamese | * Other | Date of Birth: | MM/DD/YYYY | | Household Size: | 3 | Income:(mo/yr) | | AGE Range: | * 0-18 | * 19-29 | X 30-55 | * 55 & over | Worker/Therapist: | M. Wolfrey | Duration: | 45 minutes | S: Client’s primary concern is the challenge she is having raising her 11 year old son, DJ. Client states that her son is disrespectful, does not listen to her, gets in trouble at school and is exhibiting behaviors that are concerning her. Client wants to learn coping mechanisms to counteract the high level of stress she feels while trying to parent her son. | | | O: The school SW has contacted the client to request a conference to discuss her son’s behavior at school. Client stated that her son has been fighting at school and possibly smoking cigarettes and marijuana. Per the client, he has begun hanging out with delinquent children at school. Client is overwhelmed and unsure how to handle this situation. Her spouse provides minimal support as he travels frequently for work as a truck driver. The client’s cognition is good and she appears fully alert and oriented. | | | A: The client is afraid of her son because she reports that he has “lunged” at her although she states that she is unsure if he is thinking of harming her. The client appears fearful, withdrawn, has a negative self image of herself as a parent. Client stated that she does not feel equipped to handle single parenting. She is also resentful of her husband for not being around to assist with rearing their son. Client states that when husband is home, DJ is well behaved for his father. Her husband has not witnessed the insubordination that DJ has with his mother. Client has begun to engage in drinking on a regular basis as a coping. Client isolates herself from her family as she is a very private person and doesn’t want them involved. She believes that her family will pass judgment on her and how she handles the situation. | | | P: Immediate goals for the client are to increase self care and improve communication with her spouse. Social work intern will work with client on stress and anger management through guided imagery, and will also assist in creating a safety plan for times she is fearful of the her son. The client will work with the school SW to address DJ’s behavior in school. Additional long term goals for the client are referrals for parenting classes, family therapy and referral to an ASAM 1.0 group. Social work intern will continue to evaluate client’s progress and TX plan after next session. | | | Signature: Date: |
Rev. 9/1/11
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