Following an intake session, a client file will be created where all notes from everyone in the agency who meets with the client will be added. Information related to the client’s changing needs will be noted, and goals will be created and then gauged. Progress notes, when combined with consent, prevention/intervention plans, and consent forms, tell the story of a client’s history with the agency. These are valuable artifacts used to gauge the effectiveness of service delivery.
Ingrid is a 41-year-old Hispanic mother of two who immigrated to the United States two years ago. She initially met with you to apply for public assistance and to get a mental health screening because she had not taken medication for her schizophrenia for a year.
Today is your third session with her and the primary goal of the meeting is to gauge her progress in setting appointments for the services that she and her family need. During the session, she tells you during that she had attended the mental health screening but has not had the time or money to fill her prescription. Then, she tells you that she has been having a difficult time organizing her thoughts (a symptom of her disorder). When you ask her about her other appointments, she avoids answering you directly. You set a goal for her to fill her medication by the following day and created smaller goals for accessing services because she has not managed to meet any of the other goals.
- Write a summary of the main facts from the session in the scenario.
- Imagine that you are writing her goals. What would her two main goals be after filling her medication?
- Why do you think that Ingrid did not meet any of her goals, and what would you tell her to help convince her to do so?
What other considerations would you be sensitive to concerning culture and gender?