Client Assessment

1. Client name: Freydia Jones
2. Address: 222 Troy lanes Bronx N.Y. 10454
3. telephone number: 1-718-222-2232
4. Gender: Female:
5. Age: 27
6. Religion: Christian
7. Cultural Identity: African American
8. sexual orientation: Heterosexual
9. Relationship status: Single never married
10. Employment: client is unemployed and has not received Public assistance for the past year
11. Education level completed and training: Client has graduated Kingsborough Community College with a degree in business management. Client has also completed training in Administrative Assistance and Executive Secretary.
12. Significant others: None
13. Presenting problems: Client has been actively using Cocaine in the form of crack but desires to quit and wants to reestablish custody of two children: Daughter (Dana Jones 7 years of age), and Jahiem 9 years of age. Both children are currently in the custody of grandmother, Mother of client (Edna Jones 62 years old). Mrs. Jones takes a variety of prescribed medications for Hypotension, Diabetes and Arthritis. Client believes that Mrs. Jones will not be able to continue to take care of the children. Question: In number of months or years how long have you been active? Client admits to using cocaine for the past five years since the death of her twin brother.
14. Biopsychosocial stressors: Client complains of stress and anxiety, Client has not been able to secure a job in the past five years. Worries about not being able to support her children, and the deteriorating health of her mother.
15. Client’s strengths: Client is aware of her past and present situation and is seeking help to become a responsible and respectful part of society. Client has an ideal educational background and has also completed training in other areas.
16. Family background: Client comes from a history of domestic violence as a child; Ms. Jones has one brother who was her twin, now deceased for 5 years. Twin brother was shot by a stray bullet while the two was together. Father’s whereabouts are unknown for the last 15 years. Client has two aunts and one uncle (deceased) on the mother’s side, both aunts also twins; reside in North Carolina and one uncle on the father’s side who resides in Texas. Father was known to be an active drug abuser (Cocaine).
17. Assessment of person in situation, including culture, networks, community supports, and spirituality. Client is currently receiving food stamps, medical assistance, and cash assistance from the department of human resources, but argues that she still needs to visit soup kitchens and food pantry’s to eat. Client has attend some church services.
18. Health and physical status, including medications: Client complains of constant headaches, unusual menstrual cycle, Insomnia, body aches. Client has not seen a doctor in 1year.
19. Cognitive/intellectual capacities and skills: Client displays mental distress
20. Behavioral assessment: Client showed resentment because of the negative behaviors with drug abuse that consequently led to the removal of the children from her custody.
21. Emotional/affective state: The client appeared very emotional about her present status. Client accepts responsibility for the direction of her life situation and relates desires to change present situation. Client has inquired about being able to go to a rehabilitation program immediately

Goal Assessment and Plan
Upon completion of the assessment the client felt overwhelmed about all that needed to be done to bring some order back into her life. The Client and I agreed to design a plan that will guide her towards her goals of getting custody of her children back.
Client: Ms. Brown I don’t know what to do to get my children back, but more than anything else in this world I want them back,
Ms. Brown: What do you think we need to do to make that possible? Client: I know that I need to get myself together you know, I mean get clean from drugs and petition the courts for custody. Ms. Brown: that’s correct, what do you think should be our first course of action? Client: Can you write a letter to child protective services?
Ms. Brown: If I were to write a letter today what do you think I would be able to say? Client: I don’t know, you could tell them that I really want my kids back.
Ms. Brown: It doesn’t work like that what we need to do is to have proof that you really want your children back in your custody, we can start by getting you into a rehabilitation program that you will need to complete, while you are there we can make mention of your intentions to the child protection agency, this will make them aware that you are working towards getting custody, how does that sound to you? Client: that’s fine; will I get them back after that? Ms. Brown: More than likely child protection services will ask the judge to have you complete some parenting skills classes which are usually once or twice a week for 4 to 6 weeks, how does that sound to you? Does that sound like something that you would be willing to do to regain custody? Client: I am ready to do whatever it takes, it seems this is going to take longer than I expected. Ms. Brown: You mentioned that you had a twin, Sorry about your loss, were you close or would you rather not talk about that?
Client: Yes we was close, just like my children, and now I don’t have anyone, but I rather not talk about it, I want to talk about getting my kids back.
Ms. Brown: okay that’s fine Ms. Jones I think the first thing we should do is get you on public assistance for now until you are able to pursue a job, so that you will be able to eat and go to the doctor, this will also be your means of paying for rehabilitation how does that sound to you?
Client: that sounds fantastic, I really do want to go back to work, but do you think that will take a long time I know it usually takes about 30 days for public assistance, I’m not gonna last 30 days in the streets
Ms. Brown: In certain cases we can get you emergency assistance until your regular assistance kicks in, shall we begin?
Client: Yes, but this seems like a lot to do how am I supposed to keep up with all of this? Ms. Brown: What we can do is write up a contract that will include everything we discussed and take everything step by step until you have the children back. Once that’s done you will be required to work, The Department of Human Services has programs that can help you brush up on your skills and get a job, I know it sounds overwhelming right now but we will take things one step at a time, I am here to help you. How do you feel about what we discussed? Do you need some time to think things over? Client: No I don’t need to think things over, I feel a little scared, But I’m tired of the way I’m living and I just want my kids back. This is not fair to them or my mother she’s old and sickly. Ms. Brown: Okay let’s get started.

Contract

Upon completion of interview and assessment the Client Ms. Freydia Jones agrees to take the steps listed to regain custody of her children and to obtain a job.
1. The Client agrees to enter into and complete a drug rehabilitation program. I will find a program that will assist her with her needs. The client also needs to see a medical doctor and has agreed to seek psychological treatment if necessary. The client will need to complete rehabilitation before moving further to regain custody, if the client does not complete rehabilitation she will not regain custody of the children.
2. The client agrees to abide by the rules and regulations of the child protection services in taking Parenting skills if required. I will assist the client and child protection services in the supervised visitations based on evaluation results of the client’s progress. If the client does not comply with the desires of child protection services she will be denied visitation until further notice.
3. The client has agreed to meet with me once a week to track her progress, and assess any issues that may occur. Failure to do so may result in further investigations.
4. The client agrees to actively seek employment upon completion of the job search program as a requirement of the Department of human services. I will keep track of her progress through Ms. Jones case management work, and Ms. Jones. The client is advised that while on public assistance she must actively seek work, after which her time limit will expire.

Evaluation

Ms. Brown: Hello Ms. Jones you are looking wonderful how are you feeling? How is everything going?
Client: I’m doing great, I finally finished the program and I go to meetings. My health is good but the doctor said I have to relax, Ms. Brown I am so excited and scared at the same time because I have my first visit with my kids today
Ms. Brown: that’s great Ms. Jones it seems your doing fine, I understand your excitement but tell me what makes you feel afraid about seeing your children.
Client: well we’ve been separate for almost two years now, they call me and ask when we gonna be together again?
Ms. Brown: It’s important for them to understand that you have to be well enough to take care of them. Do you think that they can understand that?
Client: Yes I do. I told them it will take a little more time but not to worry because I’m working on it.
Ms. Brown: Good and you’re doing a great job I am so proud of you.

The client Ms. Jones has entered and completed rehabilitation and parenting classes and is currently attending NA meeting regularly. She has been granted visitation rights and looks to be in very good countenance. The client has been displaying an adamant attitude concerning staying on track to regaining custody of her children. The client has started to work on her resume.
The Client has remained on track and has been complying with the contract so far. She was prescribe Tylenol for her headaches and body aches.