Can you start off saying hi Marisol , Subjective Data: Client was honorably dis


Can you start off saying hi Marisol ,
Subjective Data:
Client was honorably discharged due to an injury he had while in the military seven months ago. He injured his legs when he ran over a landmine. Client stated, “ I never…well, I just thought’Id be a career. I didn’t expect to ever leave the military. Ever. That’s been the hardest part. Getting injured was scary–the scariest thing that has ever happened to me– but now, not knowing what to do now, what I’ve got ahead for me and my family? That’s even scarier”. Client shows concerns of losing his family. He states, “I get headaches now. I don’t sleep. I can’t sleep–every time I try. I wake up to these nightmares. And then I guess I am my own nightmare during the day”.
Objective Data:
Client was well-dressed: he wore dark grey pants, with a black sweater and a dress shirt under. His hair was well groomed, and his facial hair neat. Client had a calm posture: remained upright, arms at their sides and legs slightly spread. His chin is raised and seemed to force himself to breathe naturally. Client sat straight on the couch and maintained a good eye. Client was cooperative, polite, and sincere in responding to the questions. Client is currently on a trial separation from his wife; he blames his behavior and current symptoms for the reason why his wife could not handle being around.
Assessment
Client participated in a 60-minute session. Start time 1:30 End time 2:30. Social worker began initial assessment with the client and completed the reason for the referral. Information about limits of confidentiality was done as well as informed consent. Client is a 38-year-old African American male. He was referred by the VA due to presented symptoms of headaches, not sleeping well, and having nightmares. Client shares an interest in working on behavior that has caused difficulty in his marriage. Social worker will meet with client in a week to complete the psychosocial history component of assessment.
P: Progress and/ or plan
Client will see his Primary Care Doctor to discuss headaches and difficulty sleeping and will be evaluated for PTSD. Social worker worker will develop a treatment plan and goals. Social worker will meet with client to address his behavior and sleeping issues and talk about his feelings related to his separation from his wife. Client will use relaxation techniques such as breathing techniques to relax his body and clear his mind by using calm imagery and counting, starting at 1 to 50. Client will also write in a journal every day for 1 minute until the next visit. Client is not experiencing any signs of danger to himself or others.


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