Agency: Community Mental Health Center, Minneapolis, Minnesota
Referral date: April 1, 2023
Referral source: John M., client’s brother
Client: Sarah M., age 27 (birthdate 8/15/1995)
5678 Park Avenue, Minneapolis, Minnesota
612-555-1234 (cell phone)
Family members:
Father: David M., age 60, lives in Duluth, Minnesota
Mother: Nancy M., age 58, lives in San Diego, California
Brother: John M., age 29, lives in Minneapolis, Minnesota
Presenting problem
Sarah has been struggling with depression, anxiety, and suicidal thoughts for the past six months. She has lost her job and is unable to find new employment. Sarah has a history of substance abuse, including alcohol and prescription medication. She also has a history of trauma, including sexual abuse by a family member during her childhood.
Sarah has been hospitalized twice in the past year for suicidal ideation and attempts. She was recently released from the hospital and is now living with her brother John in Minneapolis. John is concerned about Sarah’s safety and is seeking help from the Community Mental Health Center.
Transportation
Sarah does not have a car and relies on public transportation to get around. She has been struggling to keep up with her appointments at the mental health center due to difficulty navigating the bus system and lack of money for transportation. Sarah is also struggling to attend her support group meetings due to the same reasons.
Setting
Sarah is currently living with her brother John in an apartment in Minneapolis.
Identifying Information
Sarah M. is a 27-year-old female who identifies as she/her/hers. She is single and has no children.
Reason for Referral
Sarah M.’s case referral was made by her brother John due to concerns about her mental health and safety.
Relevant History
Sarah has a history of depression, anxiety, substance abuse, and trauma. She has been hospitalized twice in the past year for suicidal ideation and attempts. She recently lost her job and is struggling to find new employment. She is currently living with her brother in Minneapolis.
Assessment
Sarah has multiple issues related to mental health, substance abuse, and trauma.
The current issues exist due to a combination of past experiences and current stressors.
The strengths and resources currently available are Sarah’s support system, including her brother John, and the Community Mental Health Center.
Additional information that is needed to work with Sarah includes her medical history, current medications, and previous treatments for mental health and substance abuse.
When working with Sarah, it is important to consider her history of trauma and to provide a safe and supportive environment.
Intervention Plan
Issue 1: Mental Health
Goal 1: To improve Sarah’s mental health and reduce her symptoms of depression and anxiety.
Intervention 1: Individual therapy with a licensed mental health professional.
Client tasks: Attend therapy sessions and participate in therapy activities.
Social Work tasks: Coordinate therapy appointments and provide support and guidance for Sarah.
Goal 2: To improve Sarah’s safety and reduce her risk of suicidal thoughts and attempts.
Intervention 2: Suicide prevention plan, including safety planning and crisis management.
Client tasks: Work with mental health professional to develop and implement a safety plan.
Social Work tasks: Assist with developing and implementing a safety plan and provide crisis intervention support as needed.
Issue 2: Substance Abuse
Goal 1: To address Sarah’s substance abuse and provide support for recovery.
Intervention 1: Referral to substance abuse treatment program.
Client tasks: Attend substance abuse treatment program and participate in recovery activities.
Social Work tasks: Coordinate substance abuse treatment program referrals and provide support for Sarah’s recovery.
Issue 3
