Homework answers / question archive / APPENDIX In5: CASE—CASE INTAKE REPORT Client (fictitious name): Sum Background of Client: (Identifying information of client, e

APPENDIX In5: CASE—CASE INTAKE REPORT Client (fictitious name): Sum Background of Client: (Identifying information of client, e

Nursing

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Developmental, Family, and Social History of Client:

(Information derived from clients and/or other parties; for child clients, an interview with parent is suggested)

Live with the daughter, closer with the daughter. Have friends in the center, not able to meet friends because of the Covid-19.

Mental and Medical History of Client including Family of Origin:

(If this information is unknown to client, put “client was not aware/did not report …)

Requires regular follow-up visits to the hospital.

 

Suicidal and Homicidal Ideation

(If client had reported such ideations, you also need to put a statement at the beginning paragraph)

Did not report.

 

Clinical Impression:

(Case conceptualization with quote of reference)

She feels like trapped into the house, unaccustomed to changes in life. Always feel bored on how to spend time. She is passive on behavioral part, listens and follow her daughter’s instruction. Therefore, she does not go out for a long period. But she is active on social part, share her feeling and able to describe the details.

 

Treatment Planning:

(Based on your conceptualization, you will discuss in here the counselling goals and treatment modalities for your client)

Give space and time to relieve emotions, whatever positive and negative emotion. Provide emotional support and care in the counselling session. especially on self-identity and powerlessness part. Let the client recognize she is important, increase her self-esteem in the following session.

 

Session contents:

Session1: Receive basic information, build up relationship on counselling

 

Session2: Complain about the living for this month, due to the government polies to reduce the social distance. Positive cases increase into 10k cases pre day. Her family worried about the situation and not allow for her to leave home.

 

Session3: Share her time at home, how to spend time and kill time. She mostly walks though the house and watch YouTube. She complains that she lost her freedom and social due to the pandemic.

 

Session 4: Learn to use smart phone to download application, which can allow her to get in the restaurant or even market due to the government policies require citizen to record their whereabouts.

https://en.wikipedia.org/wiki/LeaveHomeSafe

 

Session5: Able to go out for regular follow-up visits to the hospital. Feel excited to go out for almost two months stay at home.

 

Session6: Share her family structure to me, which she has 1 son, 2 daughters. And she lives with daughter and daughter take good care for her. Because of the pandemic, she has more time to be with daughter. Be grateful for everything she owns now.

 

Session7: Share the experience and happy time that spend in elderly center. She able to join the interest class to learn skills, spend time with other elderlies. Appreciate for the staff.

 

Elder Center: Provide a variety of learning classes, volunteer services, health activities and recreational activities for people over 50 years old to serve the elderly, advocate the concept of "lifelong learning" and "active for old age", encourage community members to continue learning, and build a positive, confident, and healthy life manner.

 

Session8: Last session, she appreciates my weekly counselling session. Able to give her space to share her emotion.