Case Plan

Client Name: Fatima

Address: [Address not provided]

Phone: [Phone not provided]

Date of Birth: [Date of Birth not provided]

Special Needs Information: Requires a translator for understanding complex medical terms due to language barriers.

Intake/Review - Assessment Results:

• Fatima exhibits depression and anxiety linked to AOD misuse.
• Difficulty understanding nuances of English language influences treatment comprehension.

Information from Other Sources:

• Referred by emergency department and nurse after AOD-related hospital admission.
• Under mental health plan with Dr. Aki; receiving Cognitive Behavioural Therapy from Dr. Crane.

Clients Identified Needs (Prioritise These):

1. Address AOD misuse.
2. Improve understanding of treatment plans through consistent use of a translator.
3. Manage depression and anxiety.
4. Support for lifestyle changes to enhance overall well-being.

Goals:

Reduce AOD Dependence.

• Steps/Actions:
  • Attend regular counseling sessions with AOD support worker.
  • Join support groups to share experiences and learn coping strategies.
  • Maintain a journal to track AOD use and emotional triggers.
• Timeframe: Begin immediately, review progress every 4 weeks.

Enhance Communication and Understanding.

• Steps/Actions:
  • Use a qualified translator during all medical appointments and therapy sessions.
  • Provide translated written materials about AOD and mental health treatment.
• Timeframe: Continuous, with quarterly evaluations.

Manage Mental Health Issues (Depression and Anxiety).

• Steps/Actions:
  • Follow through with Cognitive Behavioural Therapy with Dr. Crane.
  • Use relaxation techniques like meditation, introduced in therapy.
  • Engage in physical activity, such as daily walks, to improve mental and physical health.
• Timeframe: Immediate start with bi-weekly assessments.

Develop a Healthier Lifestyle.

• Steps/Actions:
  • Work with a nutritionist to create a balanced diet plan.
  • Set a regular sleep schedule.
  • Participate in cultural or recreational activities to enhance social connections.
• Timeframe: Begin within one month, with monthly evaluations.

Counsellor Observations/Comments/Case Notes:

• Fatima shows willingness to engage in the treatment plan.
• Language barriers are significant but manageable with a translator.

Safety or Reporting Concerns (e.g. Crisis, Abuse):

• Monitor for any signs of self-harm or relapse into AOD misuse. Establish emergency contacts and procedures.

Referral/Involvement of Other Agencies:

• Ongoing collaboration with Dr. Aki (GP) and Dr. Crane (psychologist).
• Explore community support programs for AOD and mental health.

Referral Documentation Completed: Yes

Client Evaluation:

• I felt heard and understood: [Client to confirm]
• I am happy with the goals we have set: [Client to confirm]

Date of Plan: 12/04/2022 Review Date: 24/08/2022

Review/Meeting Plan:

• Regular bi-weekly check-ins with a counselor.
• Monthly interdisciplinary team meetings to evaluate progress and adjust the care plan as necessary.

Signatures:

Client: [Signature]

Counsellor: [Signature]

Guardian/Statutory Authority: [Signature] It has been 3 months since your last meeting with fatima since then she has gotten sober but has relapsed a couple of times Review the case plan and detail any changes that have happened since your first meeting and any changes that should be made. Include in your response a reflection on how your values and approaches positively or negatively impacted the overall client outcomes.