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Feb 20, 2024
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Uploaded by MinisterGalaxyArmadillo22
Soap Note Format Kim and Louis Case #6
Session #2 Intake Date 2018
Subjective: Kim is a discharged veteran who currently resides homeless due to Kim’s sister Natalie kicking her out after they lost their mother. Kim served in Afghanistan for three years and was discharged in 2012. Kim working on front line experienced onset trauma. Kim began drinking in Afghanistan to get by. When Kim returned to home she felt alone. There for, causing aggression and anxiety.
Louis and Kim at this point have a partial established rapport. Kim is aware of the identification needed to help the paperwork process. Kim starts analyzing her
emotions. Louis has concerns for the client’s well-being. Kim starts to trust Louis while in between places. Client was living out of a storage unit shed. Since
the last intake, Kim had stayed at the shelter.
Objective:
Factual Intake
Louis helped Kim navigate her feelings and emotions.
Louis connected her to a VA hot line to where she can express her anger, frustrations, and anxiety.
Louis put clear detail in the session and highlighted the importance of Kim
obtaining necessary documents which include Birth Certificate and ID.
Louis offered help to file for housing.
Louis made sure that Kim would have help of her stuff while trying to get that place.
Kim is interested with the conversation and is open for any ideas Louis can bring to the table.
Kim appeared to be upset when the other caseworker walked in.
Kim began to explain what happened in Afghanistan and being back in the
shelter is giving her uncomforting visuals of being back at the Barracks.
Assessment: Kim is open to new suggestions from her on going developing rapport with Louis. Client has struggled with depression, anxiety, and addiction due to frequent episodes of PTSD. Kim mentions that she did not process her mom’s death correctly and struggles in large crowds. Kim is afraid to seek help from others due to lingering anxiety and troubleshooting issues in her life. After seeking help from Safe Harbor, she is getting the accurate treatment she needs. She is maintaining sobriety and following medication guides.
Plan:
Louis will help Kim find and practice different coping strategies to maintain anxiety, stress.
Kim will follow up with seeking help/support from the crisis hot line and staff. Kim will develop a support list of peers for guidance.
Louis will Follow up on Wednesday to monitor progress and address any concerns.
Louis will help Kim in getting the needed documents including completing
paperwork for getting an ID. Kim will be able to obtain permanent job placement.
Note:
Collaboration between the two is vital to address all concerns and update any treatment. Louis is committed to helping Kim grow and change. Kim is open
to Louis’ help during this transition. Kim took a tour of the Safe Harbor Program. After staying with Safe Harbor, she is on medications prescribed by a physician and appears optimistic. Kim will continue to stay at Safe Harbor and continue seeking work.
Follow up in two weeks. Reference:
Cummins, l. K., & Sevel, J. A. (2018).
Social work skills for beginning direct practice:
Text, workbook, and interactive multimedia case studies
(4th ed.). Pearson
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