STUDENT INFORMATION:
Name: Alexandra Rios Team: 4 Assigned Role: Nurse Practitioner
_______________________________________________________________________________________________________________
INTAKE SUMMARY
Client Name: Sara Moore
Date Services Initiated: 3/28/2024
ID # (last four digits of social security number):9781
Address: 115th St. in East Hartford, CT 06118.
Gender: Female
Date of Birth: 03/16/1988
Education (underline highest level)
(K – 8) (High School) (Some College) (College Degree) (Post Graduate)
Employment Status (underline status)
(Unemployed) (Retired) (Employed – Part-time) (Employed Temporary) (Employed Full-time) (Self-Employed)
Seeking Change re: employment status? Underline (yes) or (no)
Source of Refe
al (underline source)
· Self
· Other (please describe): Sara viewed a story on TV about the agency and was interested in getting help.
Client Description of Situation (use quotes from the client and behavioral descriptions as much as possible)
"My name is Sara Moore. I am 36 years old and single. I’ve struggled with depression most of my life. I’ve tried more treatments and more medications than you could believe... Finally, I found a therapist who was willing to take the time to help me find a combination of therapy and medication that worked... Then the bottom fell out of my world. The bank downsized and I was laid off... I’ve been living on my savings and they are almost gone. I can feel myself sinking into depression again... I’ve started to drink to help me sleep." Sara has a long history of battling depression but has found a treatment plan that worked for her, showing her ability to engage with therapeutic interventions positively. The loss of her job has significantly impacted her mental health, demonstrating the close link between her employment status and psychological well-being.
Client Needs (use quotes from the client and behavioral descriptions as much as possible to validate and support your observations)
"I lost my health care and couldn’t afford to see my therapist or pay for my medication." Sara urgently needs access to mental health services and medication management, which are critical for her to maintain the progress she has previously made in managing her depression. "I am having trouble getting employment... Sometimes, it is too hard to make eye contact or I start to sweat." Sara is experiencing significant anxiety during job interviews, which is hindering her ability to secure employment. Support for developing coping strategies and confidence-building measures could be beneficial. "I have no health care and no way to get my medication." Immediate assistance is needed to re-establish her access to healthcare services and medication, essential for her mental health stability. "If I can’t get a job as a loan officer, I’d like to explore other job options. Maybe I could take some courses at a community college." Sara has shown interest in seeking out new job prospects and possibly pursuing additional education. She is willing to adjust her career trajectory, demonstrating resilience and a proactive attitude toward addressing her cu
ent obstacles.
Client Strengths:
-Sara's self-awareness and proactive approach to seeking help indicate a high level of motivation to improve her situation. Her previous success in managing depression with a combination of therapy and medication reflects her ability to engage with and benefit from mental health treatment.
- Holding a college degree and having professional experience as a loan officer demonstrate her intellectual capability and work ethic.
- Sara's openness to exploring new career paths and further education suggests adaptability and a willingness to grow and learn, despite cu
ent hardships.
- Openness to change and learning: Expressed interest in exploring new job opportunities and further education.
In my capacity as a Nurse Practitioner at the WSCC, I will be responsible for collaborating closely with Sara to evaluate her physical health requirements, facilitating her access to essential medication, and coordinating with mental health services to ensure a holistic approach to her well-being. It will be crucial to formulate a wellness plan that encompasses monitoring Sara's mental health condition, providing support for her employment endeavors, and exploring educational prospects. This will play a pivotal role in helping her attain stability and happiness, which are her ultimate goals.
STUDENT INFORMATION:
Name: Alexandra Rios Team:4 Assigned Role: Nurse Practitioner
_______________________________________________________________________________________________________________
ASSESSMENT AND TREATMENT PLAN
Client Name: Sara Moore
Purpose of Service: The purpose of the service is to provide mental health services to patients to assist them with their mental illnesses. The purpose is also to help the client secure a job without any anxiety. The service is also determinant to help the client develop behavioral characteristics such as self-confidence.
Client Goal/Outcome: Sara Moore’s goal is to manage her mental status by managing her depression and anxiety. She needs immediate access to mental health services and managing her medications. Sara’s goal is also to manage her anxiety issues to ensure that she gets a good job without facing interview anxiety and low self-confidence. Her immediate goal is to have proper access to healthcare services.
Activities/Services to Reach Goal/Outcome
· State what the client will do to reach the goal/outcome: Sara has self-awareness capabilities, which have made her aware of her mental health and also her need to have access to healthcare facilities. In order to reach her goals and outcomes, she needs to take counselling and therapy sessions to manage her anxiety and depression. Also, she needs proper medications and healthcare facilities to reach her goal.
· State what the worker will do to reach the goal/outcome: As a nurse practitioner, it is important to focus on the mental well-being of the patient. Also, it is important to assist Sara Moore in taking proper therapy and counseling sessions, which help her fight depression and anxiety and also will help her improve her behavioral characteristics. Ensuring that Sara is taking the right medicines on time is also a duty of the nurse practitioner. As a nurse practitioner, it is important to help the client have proper access to healthcare services.
· Describe how the activities/services are intended to reach the goal/outcome: The client is self-aware and understands her mental conditions. She is working progressively in the direction of combating her depression and anxiety issues through medication as well as through therapies. She has done this in the past as well and was successful in her efforts. She has also been expressing her interest in exploring the job opportunities and securing a job for her.
Services Provided by Agency Staff – Underline the services provided
· Direct service – consultation: Agency staff has been helping Sara through counseling and has also been helping her to have better access to healthcare services. They have also been trying to get Sara a good and secure job.
· Refe
al (describe): Refe
al in this case will include reaching out to medical practitioners, who can provide medication to Sara for good mental health.
Resources to Help Client Reach Goal/Outcome: Resources, which the agency has to help the client include multi-disciplinary staff and its community-based network of agencies and programs. They have human resources like case coordinators, nurse practitioners, caree
adult education specialists, financial specialists, mental health counselors, and substance abuse counselors to provide overall care to the client and therefore help the client reach his/her goals and outcomes.
Strengths that Will Help Client to Reach Goal/Outcome: Sara Moore’s strengths, which will help her reach her outcomes include a high level of motivation and self-awareness. She is proactive and is working progressively to improve her mental health. As far as the strengths of the agency need to be considered, they have trained staff, with education and experience in various disciplines and therefore help in the overall well-being of the client. The staff of the agency has been working in close coordination with the clients to know their problems and difficulties and then assist them to be better accordingly.
Describe what it will look like for the client when the goal/outcome is reached. What will be different in the client’s life?
When the goals and outcomes are reached, Sara will have improved self-confidence and a secure job. She will have good mental health and she will be free from any sort of anxiety or depression. Also, Sara will have a better skill set and behavioral characteristics, which will help her build a better future.
Imagine that you've been working with your client for six months. Together, you and Sara Moore client decide it is time to assess the status of progress toward goals/outcomes. You and your client will use a Likert scale to assess progress or lack of it. Using a Likert scale will help you and your client to figure what, if anything, needs to change in the treatment plan to help her reach her goal/outcome. Periodic assessments of progress toward goal/come achievement increase the likelihood that clients reach their goals/outcomes and give you the opportunity to demonstrate your role in goal/outcome achievement.
Continue to include direct quotes from your client. Your creativity can shine here as you imagine a meeting or call or Zoom with Ms. Moore to create the progress report.
Create a draft progress report, using the form below. Use as much space as you need in the form, save it to your computer, then post it to the discussion. Posting a draft of the status report keeps your team informed and provides the opportunity for you to respond to questions.
PROGRESS REPORT FORM
I provided:
1. I also provide a separate document of the form you have to fill out. Remember my role of the agency is a Nurse practitioner.
2. I also provided below what is the agency.
3. Sara Moore Case
4. I attached the assessment and intake form so you can take a look at it.
The Wallace Stevens Community Center*
Agency Mission: The Wallace Stevens Community Center (WSCC) seeks to support, strengthen, and empower adults in the north country by providing them with access to a wide variety of services including medical, mental health, continuing education, housing, career counseling, and temporary financial assistance.
Agency Outcome Goals: The adults who are served by the Wallace Stevens Community Center will achieve ongoing stability as evidenced by:
· Completing client education goals within 2 years from the initiation of service
· Obtaining stable employment within 1 year from the initiation of service
· Obtaining stable housing within 3 months from the initiation of service
· Achieving physical and psychological wellness or management of chronic medical conditions within 1 year from the initiation of service
Agency Description: The Wallace Stevens Community Center (WSCC) provides a
oad a
ay of services through its multi-disciplinary staff and its community-based network of agencies and programs. The central office of the WSCC is located in Glens Falls with satellite offices throughout the north country to provide access to services to individuals in remote rural areas.
Agency Operations
Each office is staffed with a case coordinator, nurse practitioner, caree
adult education specialist, financial specialist, mental health counselor and substance abuse counselor. Each office will use the same management information system to demonstrate accountability to its executive board, its funders, its clients and other community stakeholders; to evaluate the efficacy of service delivery at the individual practitioner and organizational levels (whether services enabled clients to reach outcome goals), and to communicate within the agency and externally with key stakeholders and the community.
Agency Treatment Approach
As a staff member of WSCC, you are expected to work with clients and each other according to the principles of a strengths-based, solution-focused practice. When employing a solution-focused practice:
· Clients are given an opportunity to describe their needs and problems.
· The service provider assists the client to identify their strengths and resources.
· The service provider works with clients to develop well formed goals as soon as possible inviting the client to consider “What will be different in your life when your needs are met and your problems are solved?”
· The service provider asks clients to consider a time when their needs were met and their problems were not present.
· The service provider assists clients to consider how they can use their strengths and supports to solve their problems.
· At the end of each meeting, the service provider summarizes agreements and next steps, including activities to reach goals, and who is responsible for doing what.
Agency Treatment Teams
Throughout agency involvement, service providers and clients evaluate the progress being made toward reaching satisfactory solutions and meeting needs.
As a staff member of WSCC, you are expected to collaborate with your colleagues as a member of a treatment team. Each member of the treatment team will serve the client according to his or her role and specialty. Each member of the treatment team will collaborate with the team and client to identify client needs and strengths. Each team member will work with the client to identify outcomes and activities to achieve them and communicate the goals and progress toward them to the team. Each member of the team will refer clients to community-based agencies as needed.
Agency Refe
al Network
The staff of WSCC will supplement the direct service that they provide with refe
als to a variety of community-based services including, but not limited to the Adirondack Food Pantry and Fresh Food Network, the Lewis, Washington, St. Lawrence, Wa
en, Essex, Clinton, Herkimer Counties of Departments of Social Services and Health and Mental Health, Adirondack Community College, United Churches and Synagogues Community Services Center, Volunteers for North Country Wellness, the North County YMCA and YWCA, Volunteers in Service to America, Supporting Our Greatest Resource: Our Neighbors, the North Country Business Association’s not for profit public service agency and Pro Bono Legal Services.
This is my role in the agency is a
Nurse Practitioner – Responsible for refe
ing patients to a physician for initial diagnosis and treatment. With the client, develop and