You will be creating intake notes, case/ progress notes, and demographic informa

You will be creating intake notes, case/ progress notes, and demographic information such as where he lives currently, programs that he’s involved with, and any past history that you may need for the client. You are acting like the case manager for the client and you will have to document any demographic information that you need for your client.
Client #1
Stanley is a 64-year-old male
Lived with his mother until five years ago
Lived with his brother and wife until 6 months ago
Currently lives in a group home
Rarely talks, but can
Appears to understand English, but their family is Francophone and he clearly understands French
History of being physically and verbally abused by mother and brother
Maintains a strong bond with mother who visits once a month
Known to strike out at support workers and randomly has violent moments
Currently medicated with mood stabilizers, and anti-psychotics
Stanley is only partially mobile and requires a walker to move around
Stanley also exhibits behaviours indicative of an obsessive-compulsive disorder
The House manager has contacted your agency and requested a Case File Worker to work with Stanley
Any further information about this client you will need to detail
Client #2
Ryan is a 50-year-old male
Retired RCMP (Mandatory)
Does have sessions with a Psychologist in the city
Needs to rethink his career/ educational choices
Has been getting more aggressive towards his spouse
Is trying to adjust to life without his fellow R.C.M.P. members
Feels very depressed about his future
Feels very anxious sitting around right now
He does not socialize much anymore and feels isolated
Has two grown sons who are in College
Has been referred by his Psychologist after his spouse found him passed out in the backyard lounger during a rainstorm
Client # 3
Daniel is a 32-year-old female
Has been in recovery for 12 months from a heroin addiction
Has a 6-month-old son
Both Mom and Son are in need of adequate shelter
Daniel was staying with a sober friend for the past 12 months but needs her own place as tension has been building between her and the roommate
Has good supportive family but they live three hours away and can only visit every few months
She wants to stay living in the city
Lately, she has been feeling very worried about her future
Wants to educate herself further
Has to finish her Grade 12
Is currently taking Suboxone but wants to eventually be off of it
Does not have much support in the city by herself and is in need of parental supports as well
Does not have her own transportation
Lives on Income Support
Was homeless prior to getting into a recovery center
Has been referred to you by her Social Worker
Minimum Requirements
This Plan of Care must contain the following information:
Types of assessment and assessment schedule to be used to determine services and needs of the client
Client’s goals and timeline to reach goals
Services provided to the client to meet goals
Types of monitoring that will be used and monitoring schedule. Who will monitor and who will be monitored?
Any supporting office documentation such as letters of request, proposal letters, memos, or flyers related to this client and services within the care plan
You will also develop an intake form with necessary information from the client (you will have to create this on your own by following the textbook information and by creating it for the client.)
Include all the information stated for your client along with making it up for the information you don’t have. For example, when doing history for the client you will decide their personal histories such as parents – living or deceased and what kind of relationship they had with extended family – along with educational/ vocational history. You will also include any medications that you suspect they may be on. You are creating this from the ground up. The textbook provides good information on what all goes into a case file.