Case Managenent Summary Case Record

Due as as possible but no later than tomorrow Monday 12/14/15  by 17:00 (5:00 PM) Write a summary of Jeannie’s case record. Your summary should be 1 page or less in length. Be sure to select carefully the details that you feel are most important.


See attached for Jeannies case record and the record for you to fill out for this assignment




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1 | I n t a k e A s s e s s m e n t F o r m

Brook Grove Treatment Center

7433 West Embers Path

Red Leaf Cove

Intake Assessment Form

Client Jeannie Smith Case 456789

DOB 07/08/1962 Unit 15


Date of assessment 08/05/2012

Presenting problem Jeannie is a 50 year old woman who came in because she was struggling with depression. She said her husband of 20 years was an alcoholic and a batterer. She said her main reason for coming in was because of her marriage but when questioned she said that she drank vodka on a daily basis but could stop whenever she wanted too. She reported that she had used drugs on a heavy basis when she was in college but denied use now. She said she had taken over the counter diet pills but was not concerned about that. She denied blackouts but said she was scared about her health because she said sometimes when she drank she had heart palpitations. She also admitted to hiding liquor but said she did this so her kids wouldn’t find it.

Current client involvement with other agencies

Agency/contact – None reported Phone/email Service Date


Assessment of life circumstances Family

She has 3 children but they were still young and not a support for her. She denied any other support.

Social She reported that she is pretty isolated and only stays at home with her children.

Support She denied any other support.

Legal Jeannie reported never having any legal issues.


She said she had a B.S. degree and a teacher’s certification. She had started work on a Master’s degree but did not finish. She said school was her only outlet.


Jeannie is a teacher who reported that she was recently laid off. She was unable to get another job.

Finances She reported no financial difficulties.

Psychosocial and environmental

She said the only problem was her ex abusive husband but she was not concerned.


Current medical conditions

Condition – Anorexia Physician/provider – Dr. Max Jones Treatment – Counseling



2 | I n t a k e A s s e s s m e n t F o r m

Condition – Heart palpitations Physician/provider – Did not see a doctor Treatment – Not currently treated

Pregnant If yes, receiving care? N/A

Primary care physician

Dr. Janey Baker

Current medications Medication – None reported Dosage Prescribed by Condition Side effects Any medication allergies? – None reported

Risk factors Does client feel safe at home? __ Yes __ No _X_Maybe Does client feel threatened? __ Yes _X_ No If yes, describe: Jeannie said that she thought she was safe in her new apartment but was still afraid of her ex-husband.

Abuse Has client been abused in any way? _X_ Yes __ No If yes, check all that apply: _X_ Physical __Emotional _X_Sexual Relationship of perpetrator to client: Husband and, previously, father. Any legal action taken? There was no legal action taken in either case because she was afraid of retribution from her ex-husband if he were arrested and then got out of jail. She was afraid he would come after her. She also did not press charges against her father.

Safety Does client have safety plan? __ Yes _X_ No Does client need shelter? __ Yes _X_ No Does client need protection order? _X_ Yes __ No

Suicide/ Violence Client’s self-rating of (scale of 1=none, 2=slight, 3=moderate, 4=extreme or immediate): Suicide risk – 1 Becoming violent – 1 Homicide risk – 1





3 | I n t a k e A s s e s s m e n t F o r m

Mental status exam Appearance __ Age appropriate _X_Well groomed __ Disheveled/unkempt __Bizarre

__ Other:

Orientation _X_ Person _X_ Place _X_ Time _X_ Situation

Behavior/ eye contact __ Good _X_ Limited __ Avoidant __None __Relaxed/calm _X_ Restless __Rigid __ Agitated __Slumped posture _X_ Tense __Tics __ Tremors

Motor Activity __ Mannerisms __ Motor retardation __ Catatonic behavior

Manner _X_ Appropriate __ Trusting _X_ Cooperative __ Inappropriate _ _ Withdrawn __ Seductive __ Playful __ Evasive __ Guarded _ _ Sullen __ Passive __ __ Defensive __ Hostile __ Manic __ Demanding __ Inappropriate boundaries

Speech _X_ Normal _X _ Incoherent __ Pressured __ Too detailed _ Slurred __ Slowed __ Impoverished __ Halting __Neologisms __ Neurological language disturbances

Mood __ Appropriate _X _ Depressed __ Irritable __ Anxious __ Euphoric _ _ Fatigued _ _ Angry __ Expansive

Affect __ Broad _X _ Tearful __ Blunted __ Constricted _ _ Flat __ Labile __ Excited __ Anhedonic

Sleep __ Good _X_ Fair _ _ Poor __ Increased __ Decreased __ Initial insomnia _ _ Middle insomnia __ Terminal insomnia

Appetite __ Good _X_ Fair _ _ Poor __ Increased __ Decreased __ Weight gain __ Weight loss

Thought process _X_ Logical and well organized _ _ Illogical __ Flight of ideas __ Circumstantial __ Loose associations __ Rambling __ Obsessive __ Blocking __ Tangential __ Spontaneous __ Perseverative _ _ Distractible

Thought content __ Delusions __ Paranoid delusions __ Distortions _ _ Thought withdrawal __ Thought insertion __ Thought broadcast __ Magical thinking __ Somatic delusions __ Ideas of reference __ Delusional guilt _ _ Grandiose delusions __ Nihilistic delusions __ Ideas of inference

Perception/ hallucinations

__ Illusions __ Hallucinations __ Depersonalization __ Derealization

Suicide risk _X_ None __ Slight __ Moderate __ Significant __ Extreme __ No plan __ Plan (describe):

Violence risk _X_ None __ Slight _ _ Moderate __ Significant __ Extreme



4 | I n t a k e A s s e s s m e n t F o r m

__ No plan __ Plan (describe):

Judgment __ Intact __ Age appropriate _X_ Impulsive __ Immature __ Impaired __ Mild __ Moderate __ Severe

Insight _X_ Intact __ Limited __Very limited __ Fair __ None __ Aware if current disorder __ Understands personal role in problems

Sensorium __ Alert __ Drowsy __ Stupor __ Obtundation __ Coma

Memory _X_ Intact __ Impaired __ Immediate recall __ Remote __ Amnesia Type of amnesia:

Intelligence __ Average _X_ Above average __ Below average __ Unable to establish


Substance Use/Abuse Type Substance/

Amount used How taken Duration Frequency Last date of


Tobacco 2 packs Smoked 20 years Daily 1995

Alcohol Vodka fifth Orally 5 years Daily Yesterday

Illicit drugs

Marijuana Smoked Occasional Weekly Didn’t remember

LSD Orally Occasional Monthly College

Cocaine Snorted 3 years Daily College

Amphetamine Orally 10 years Daily 2 years ago

Prescription drugs

None reported

OTC drugs Diet pills Orally 5 years Daily Last year

Other None reported


Experiencing Yes No

Withdrawal X

Blackouts X

Hallucinations X

Vomiting X

Severe depression X

DTs and shaking X

Seizures X

Other Describe:



Patterns of Use Yes No

Uses more under stress X

Continues use when others have stopped X



5 | I n t a k e A s s e s s m e n t F o r m

Has lied about consumption X

Has tried to avoid others while using X

Has been drunk/high for several days at a time X

Neglects obligations when using X

Usually uses more than intended X

Needs to increase use to become intoxicated X

Has tried to hide consumption X

Sometimes uses before noon X

Cannot limit use once begun X

Failed to keep promises to reduce use X


Describe attempts to stop

She denies a problem and says she can stop whenever she too – but has not tried.

Describe circumstances that usually lead to relapse


Is client involved in AAINA? __ Yes _X_ No





6 | I n t a k e A s s e s s m e n t F o r m

Summary of Findings Interviewer summary of findings (add details where appropriate)


Client requests, goals, expectations

Jeannie was curious as to why she spent so many years in a marriage that was abusive. She was also curious about her past drug use and promiscuous sexual behavior and the reasons for this. She requested help with these issues.

Clinical summary



Case Manager Signature




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