Discharge Summary - Case Study PDF

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Discharge Summary Directions: Complete the Discharge Summary form. Client Name: Allison Williams

Date of Birth: 1/26/1996

Date of Admission:

Date of Discharge: 8/30/2020

8/9/2020

Presenting problem upon admission: The client is in a state of depression and having thoughts of suicide due to past hurts and other abandoning her weather its family, friends, or past relationships. This depression has led the client in a downward spiral seeking alcohol and marijuana to dull the feelings of pain and the emotions of worthlessness. Also, the client has use pain pills such as 250 milligram ibuprofen and marijuana in order for her to sleep at night, she stated “it helps me sleep.” She reports that she has stopped attending classes and her grades are failing. The client was fired from her job as a waitress two months ago, because the client frequently missed work and when the client was there, the client’s boss told her she was just “not friendly to the customers.” The client also reports that she is feeling overwhelmed.

Current Medication: The client is currently taking Zoloft for depression and told not to use any drugs or alcohol

Reason for Discharge: The client has been compliant with all treatments group counseling twice a week for substance abuse, and individual counseling twice a month. The client has been taken their medicine on a regular basis and has been following up with her counselor and case manager Case Manager Follow Up: follow up with the client in 30 days to see how her recovery is going and also to assess her recovery progress Resources & Referrals: With a release of authorization, the case manager has referred the client to the local group counseling twice a week, cognitive behavioral therapy once or twice a week for 30- to 60-minute sessions over 12 to 20 weeks, attend alcohol anonymous once a week for 1 hour for the next 9 weeks, and Dialectical Behavior Therapy (DBT) Individual treatment once a week for 1.5 hour for the next 9 weeks.

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Allison Williams , ##/##/## Client Signature & Date

Cotia Wallace 8/30/2020 Case Manager Signature & Date

© 2015. Grand Canyon University. All Rights Reserved....