Client records

Community Services Client Record C LIENT P ROFILE R ECORD ( HYPOTHETICAL ) Client Name: John Address: Moe Contact no: 1234567 Client’s age: 23 years old Male: ☒ Female: ☐ Other: ☐ (Please tick) Married: ☐ Single: ☒ Separated: ☐ Other: ☐ (Please tick) Client’s presenting co-existing issues: Depression and alcohol Client’s Strengths: Motivation to change. Client’s Weaknesses: Self-medication Services provided: Refer to GP for depression. Alcohol to Rehabilitation Early intervention Exercise program to rehabilitated depression. No alcohol at home. Goals Improving overall wellbeing Achieve sobriety and manage depression. Timeline and deadlines Seek professional help. Develop treatment plan. Attend regular counselling. Sobriety milestone Developing coping mechanism Engage in ongoing therapy and support network. John has been suffering from depression for a while now and has been using antidepressants to cope with his symptoms. He has recently started drinking and is aware that he is now dependent; he cannot go about his daily duties without a drink. The risk of drinking alcohol while taking antidepressants can be significant. John’s alcohol consumption can have a complex effect on the antidepressants he takes. In certain circumstances, alcohol can completely negate the advantages of antidepressants. John could potentially worsen his depression or increase the side effects of his medication. The combination of alcohol and antidepressants can lead to enhanced drowsiness, sedation, and incoordination as alcohol is a depressant. o As per John answer on patient health questionnaire. (attached) o Client consent signed form. (attached) o Shared information with other disciplinary o Check progression report. o Risk Assessment within organization and clients o Self Evaluation

Client profile record completed by: Nila Lauw Date: 13 November 2023 (Name and Signature of Assessment Officer)

o As per Papita answer on patient health questionnaire. (attached) o Client consent signed form. (attached) o Shared information with other disciplinary o Check progression report. o Risk Assessment within organization and clients o Self Evaluation Client profile record completed by: Nila Lauw Date: 13 November 2023 (Name and Signature of Assessment Officer)

Community Services Client Record C LIENT P ROFILE R ECORD ( HYPOTHETICAL ) Client Name: Rex Address: Moe Contact no: 1234569 Client’s age: 39 years old Male: ☒ Female: ☐ Other: ☐ (Please tick) Married: ☐ Single: ☒ Separated: ☐ Other: ☐ (Please tick) Client’s presenting co-existing issues: Schizophrenia and caffein Client’s Strengths: Awareness of symptom Adaptive coping mechanism Persistence in daily life Client’s Weaknesses: Excessive caffeine dependence Sleep disturbances Isolation and limited social support Services provided: Refer to; psychiatric evaluation and medication management. Sleep hygiene education Nutrition guidance Holistic health and wellness program Education program Early intervention Engagement with mental health professional Substance abuse treatment Family and social support Psychoeducation Goals Stabilised schizophrenia symptoms. Reduce caffein dependence. Timeline and deadlines Immediate psychiatric assessment Medication adjustment and therapy initiation Regular follow up Evaluate symptom improvement. Caffein reduction plan Introduction of alternative coping strategies Assess long term reduction and sleep quality. Rex has been dealing with schizophrenia from his adult life. His symptom is managed by medication; however, he still experiences hallucinations, delusion, mood swings, and sometimes depression. Sleeping rarely occurs for him, and when he does, its short lived. To combat his fatigue, he uses caffeine. Throughout the day, he drinks coffee and sometimes adds an energy drink for extra boost.