Date
stringclasses 9
values | Social Worker
stringclasses 1
value | Client
stringclasses 2
values | Case Note
stringlengths 185
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January 3, 2023 | Jane Smith | Alex D. | Met with Alex at school following reports of increased absences and declining grades. Alex appeared sullen and avoided eye contact. When prompted about school, Alex expressed feelings of isolation and stated, "No one gets me." Scheduled a follow-up meeting to further explore these feelings. |
January 17, 2023 | Jane Smith | Alex D. | Met with Alex at the community center. Alex displayed sudden outbursts of anger when discussing home life, particularly in relation to a new stepfather. Alex mentioned occasional substance use, but did not specify which substances. Recommended a comprehensive assessment. |
February 5, 2023 | Jane Smith | Alex D. | Home visit conducted. Alex's mother reported frequent arguments at home. She expressed concerns about Alex's new group of friends and late-night outings. Noted potential signs of substance abuse. Suggested family counseling. |
February 21, 2023 | Jane Smith | Alex D. | Met with Alex alone at my office. Alex appeared more agitated than in previous meetings. There were visible signs of self-harm on Alex's arms. When questioned, Alex became defensive. Immediate referral made to a mental health professional. |
March 10, 2023 | Jane Smith | Alex D. | Attended joint session with Alex and a therapist. Alex shared feelings of hopelessness and admitted to occasional thoughts of self-harm. Therapist recommended a comprehensive mental health evaluation and ongoing therapy. |
March 25, 2023 | Jane Smith | Alex D. | Received a call from Alex's school about a physical altercation with another student. Met with Alex, who displayed high levels of frustration and admitted to the use of alcohol. Discussed the importance of seeking help and finding positive coping mechanisms. Recommended enrollment in an anger management program. |
April 15, 2023 | Jane Smith | Alex D. | Met with Alex and mother to discuss progress. Alex's mother expressed concerns about Alex's increasing aggression at home. Alex acknowledged the issues but blamed others for provoking the behavior. It was decided that a more intensive intervention may be needed. |
April 30, 2023 | Jane Smith | Alex D. | Met with Alex and a psychiatrist. Psychiatrist diagnosed Alex with Oppositional Defiant Disorder (ODD) and co-morbid substance use disorder. A treatment plan was discussed, including medication, therapy, and family counseling. |
May 20, 2023 | Jane Smith | Alex D. | Met with Alex to discuss progress. Alex has started attending group therapy and has shown slight improvements in behavior. Still, concerns remain about substance use. Discussed potential for a short-term residential treatment program. |
January 3, 2023 | Jane Smith | Jamie L. | Met with Jamie at school after receiving reports of consistent tardiness and decreased participation in class. Jamie appeared withdrawn and exhibited signs of sadness. When asked about feelings, Jamie expressed feeling "empty" and "hopeless" at times. Scheduled a follow-up meeting to further explore these feelings. |
January 17, 2023 | Jane Smith | Jamie L. | Met with Jamie at the community center. Jamie shared feelings of low self-worth, mentioning that it's hard to find motivation for daily tasks. Discussed potential triggers and learned about recent family financial struggles. Recommended counseling and possible group therapy for peer support. |
February 5, 2023 | Jane Smith | Jamie L. | Home visit conducted. Jamie's parents shared concerns about Jamie's increasing withdrawal from family activities and lack of interest in hobbies. Parents mentioned that Jamie spends a lot of time alone in the room. Suggested family therapy to open communication channels. |
February 21, 2023 | Jane Smith | Jamie L. | Met with Jamie in my office. Jamie opened up about feelings of isolation and mentioned difficulty sleeping. No signs of self-harm or suicidal ideation were noted. Recommended a comprehensive mental health assessment to better understand the depth of the depression. |
March 10, 2023 | Jane Smith | Jamie L. | Attended a joint session with Jamie and a therapist. The therapist noted signs of moderate depression. Together, we discussed coping strategies and potential interventions. Jamie showed interest in art therapy. |
March 25, 2023 | Jane Smith | Jamie L. | Received feedback from Jamie's school that academic performance has slightly improved. However, social interactions remain limited. Encouraged Jamie to join school clubs or groups to foster connection. |
April 15, 2023 | Jane Smith | Jamie L. | Met with Jamie and parents to discuss progress. Parents have observed slight improvements in mood on some days, but overall, Jamie still appears to struggle. It was decided to explore medication as a potential aid alongside therapy. |
April 30, 2023 | Jane Smith | Jamie L. | Met with Jamie and a psychiatrist. The psychiatrist diagnosed Jamie with Major Depressive Disorder (MDD) and suggested considering antidepressant medication. Discussed the potential benefits and side effects. Jamie and parents will think it over. |
May 20, 2023 | Jane Smith | Jamie L. | Jamie has started on a low dose of an antidepressant. Initial feedback is positive, with some improvement in mood and energy levels. Will continue monitoring and adjusting as necessary. |
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