XYZ Community Mental Health Center Recovery is Possible!
PROGRESS NOTE
Summary Information for Collette Rose
Name: Collette Marie Rose
SSN: 333–45–6668
DOB: December 4, 1978
Case Worker: Will Jones
Agency: XYZ Community Mental Health Center 5678 That Street Some Town, YY 12345 Phone: 111-222-3333 Fax: 111-222-4444
Some Town, YY 12345 Phone: (111) 222-3333 Fax: (111) 222-4444
Page: 1
XYZ Community Mental Health Center Recovery is Possible!
PROGRESS NOTE
Date: February 22, 2012 Case Worker: Will Jones Consumer: Collette Rose Location: Outreach – Drop-in Day Center – 5th and Main St.
Narrative:
Case manager (CM) met Collette Marie Rose at the 5th & Main Day Center. She is Caucasian, 5’3”, approximately 160 lbs, with brown hair and brown eyes. She appears to have depressed mood and it looks like she has been crying. Her face was red, tear stained, and she was not wearing any makeup. She wore clothing appropriate to the weather, but it appears wrinkled and unwashed.
I introduced myself to Collette and let her know about outreach services from XYZ. She states that this is her first time to the day center and she is not receiving any services in the community. Collette reports that she has been “bouncing around” living situations her whole life, but is currently staying in her car. She sometimes stays with her half-sister, but never for more than a night or two. Collette cried off and on throughout the meeting and displayed a feeling of hopelessness as she talked about how “things will never get better” for her. She reports that her three year old daughter, Layla, has been in Child Protective Services (CPS) custody for almost a year.
I asked Collette if she has applied for SSI/SSDI benefits and she states that she hasn’t because she feels she isn’t qualified for them. When I asked why she felt that way, Collette began to cry and disclosed that she has been arrested in the past. I reassured Collette that having a legal history does not disqualify her and gave her a brief overview of the application process. Collette agreed to meet me again on Friday to discuss starting a SOAR application.
When I asked Collette if there is a way to contact her if I need to give her a message, she replied that she does not have a phone and was reluctant to tell me where she parks her car at night. I gave her my contact information and asked her to keep in touch with me.
We will meet February 24, 2012 at the Day Center.
Some Town, YY 12345 Phone: (111) 222-3333 Fax: (111) 222-4444
Page: 2
XYZ Community Mental Health Center Recovery is Possible!
PROGRESS NOTE
Date: February 24, 2012 Case Worker: Will Jones Consumer: Collette Rose Location: Outreach – Drop-in Day Center – 5th and Main St.
Narrative:
CM attempted to meet Collette at the Day Center; however, Collette was not present and staff reported that they have not seen her since we last met. As Collette did not provide information on how to contact her, CM will continue to look for her in the community to talk with her about SOAR.
Some Town, XX 12345 Phone: (111) 222-3333 Fax: (111) 222-4444
Page: 3
XYZ Community Mental Health Center Recovery is Possible!
PROGRESS NOTE
Date: March 19, 2012 Case Worker: Will Jones Consumer: Collette Rose Location: Outreach - Drop-in Day Center – 5th and Main St.
Narrative:
CM met Collette on the street outside of 5th & Main Day Center. Collette appears to have good hygiene and is wearing a dress shirt and pants. Her hair is styled and she is wearing blue eye shadow and pink lipstick. CM asked Collette if she had given thought to working with CM on an SSI/SSDI application and she states that she no longer needs disability.
Throughout the short conversation, Collette displayed delusions of grandeur, as evidenced by plans to publish a book that will sell millions of copies, and taking her daughter (whom she does not currently have custody of) to Europe. Collette spoke rapidly, with tangential thought pattern and flight of ideas, and she repeatedly asked if I have been on an airplane. She rapidly repeated questions to me without waiting for answers and suddenly ended the conversation by exclaiming in an exaggerated manner, “I’ve gotta go, I’ve gotta go!” and running across the street.
CM will continue to try and meeting Collette in the community and engage her about a SOAR application.
Some Town, XX 12345 Phone: (111) 222-3333 Fax: (111) 222-4444
Page: 4
XYZ Community Mental Health Center Recovery is Possible!
PROGRESS NOTE
Date: May 14, 2012 Case Worker: Will Jones Consumer: Collette Rose Location: Outreach Office
Narrative:
CM received referral for Collette Rose from the social worker at Any County Jail, Mental Health Services. The referral states that Collette has been incarcerated since 4/01/12, but will be released soon (6/01/2012) and the social worker would like us to assist Ms. Rose with SSI/SSDI benefits.
CM previously met Collette on two occasions approximately 2-3 months ago and spoke with her about services; however, Collette refused at that time. During the previous meeting, Collette was displaying manic symptoms and told this writer that she was going to write a book about her experiences instead of applying for disability.
CM called the jail and made an appointment to meet with Collette tomorrow to talk with her about an SSI/SSDI application.
Our Town, XX 12345 Phone: (123) 456-7891 Fax: (123) 456-7892
Page: 5
XYZ Community Mental Health Center Recovery is Possible!
PROGRESS NOTE
Date: May 15, 2012 Case Worker: Will Jones Consumer: Collette Rose Location: Any County Jail
Narrative:
CM met Collette at Any County Jail, where she is currently incarcerated. She presents with depressed mood and flat affect. Her clothes appear wrinkled and it looks like she has been crying. During the interview, Collette spoke slowly and had poor eye contact. Collette stated that she does not remember me, despite meeting twice before.
Collette reports that she experiences difficulty sleeping and states that she only sleeps a few hours in the daytime, never at night. She has been sleeping in her car, but often walks around until 3am because she cannot sleep. Collette reports trying to stay away from people and does not like participating in groups. When asked about this, she became suddenly angry and stated, “My life is none of their business.”
Education: finished the 8th grade and left school in the 9th. When talking about this, she became tearful and stated, “I didn’t finish school because I don’t finish anything.” She reports that before leaving school she got A’s and B’s and that a teacher helped her manage schoolwork.
Children: has a 3 year old daughter (Layla Ann Rose) in CPS custody. Has 16 year old son (James, aka “Jimmy”) who is currently in juvenile detention. No current contact with either child. She reports that Jimmy never wants to see her.
Family: Born in Middleton, PA. Raised by her mother, who drank “a lot” and “always had men coming and going.” Reports that some of her mother’s relationships were violent. Collette never knew her father. When Collette was 11, her mother married and had 3 children– Collette reports that her step-father liked her “a little too much.” Collette still maintains contact with half-sister Stephanie Montaine. She states that she sometimes worries that Stephanie secretly has contact with her family.
Collette expressed agitation when talking about her family and requested we end the interview. CM explained the SSI/SSDI application process and the SSA-1696 representative form, and Collette signed the SSA-1696.
CM explained release of information forms for treatment facilities. Collette states that she has received treatment at County General Hospital. Collette signed releases and SSA-827 forms for
Some Town, YY 12345 Phone: (111) 222-3333 Fax: (111) 222-4444
Page: 6
XYZ Community Mental Health Center Recovery is Possible!
PROGRESS NOTE
County General Hospital, Any County Jail and releases for me to speak with her half-sister, Stephanie Montaine. I also had Collette sign a release to access any records available from Child Protective Services.
Of note, when signing the forms, Collette moved very slowly and I repeated the instructions for her multiple times. A few times she stared at the page, but did not appear to be reading the material and required prompting from me about which form we were on and why. On another form she became distracted from something happening in the room adjacent to ours and required additional prompting that we needed to complete the form. She signed the forms slowly and repeatedly asked for today’s date.
I also asked Collette if someone had talked with her about when her release date might be from jail and she responded, “I don’t know. I don’t even know why I’m in here – it’s some shop- lifting thing. I’m always in here for one reason or another.” Collette did not wish to discuss her legal history and I will try to gather this information from her jail records.
CM will meet Collette in a week at the jail to complete service plan and continue to gather information for SSI/SSDI claim.
Some Town, YY 12345 Phone: (111) 222-3333 Fax: (111) 222-4444
Page: 7
XYZ Community Mental Health Center Recovery is Possible!
PROGRESS NOTE
Date: May 16, 2012 Case Worker: Will Jones Consumer: Collette Rose Location: Outreach Office
Narrative:
CM called Stephanie Montaine (phone: 111-222-3487) – Collette’s half sister. Stephanie reports that she is happy to provide any information needed for the disability application and that she wants to help Collette find a place to live so that she can get custody of her children back. She states, “I really want her to be able to see Layla, but I’m not sure she is capable of taking care of herself, never mind a child.”
Stephanie reports that she has let Collette stay at her house numerous times over the past few years and has cared for Collette’s children, Jimmy and Layla, when Collette “just couldn’t do it.” When asked what that meant, Stephanie replied, “It’s because of those kids that I let her keep coming back. Kids need structure, and someone to care for them. I have to make her bathe and eat, and even change her clothes. When she gets depressed, there’s no way those kids are getting baths and good food. She can’t even take care of herself when she’s depressed. Her self-esteem is so low, that she doesn’t make any effort to look good. She was really beautiful as a young woman…Now, sometimes I drag her out of bed and make her shower, but I have to stand there encouraging her.”
When I asked Stephanie if Collette helps with the cleaning or laundry, Stephanie laughed and replied that she doesn’t think Collette knows how to do those things. Stephanie does all the household tasks for Collette and her children.
Stephanie also states that she worries about Layla living in a car with Collette, and explains that she doesn’t have the resources to care for Collette’s kids herself, as she has three kids in a two- bedroom apartment. She states, “I’ve done what I can. That car – it’s not even hers. I bought it for her, but it’s all in my name. It’s old and run down, but at least it’s something. I thought it might help her and the kids. It’s not much, but I’ve done what I can.” Before Layla was in CPS custody, Stephanie took care of her a few times when Collette was living in her car or with a boyfriend.
When asked about their childhood together, Stephanie reports that she and Collette were molested by Stephanie’s father. She states, “It’s been like this Collette’s whole life – she’s been hurt by so many men. First, my father and then I’m sure she was molested by her foster dad. After that she took up with this guy, Tito, and he forced her to have sex with his friends. It’s not
Some Town, YY 12345 Phone: (111) 222-3333 Fax: (111) 222-4444
Page: 8
XYZ Community Mental Health Center Recovery is Possible!
PROGRESS NOTE
any better now. When she lives in her car, she just isn’t safe. I know she has been raped many times. Lately, Collette has been reluctant to talk about any boyfriends.”
Stephanie ended the conversation because she had to go to work, but states that if we need additional information for Collette’s application that we can contact her again. CM will follow up as necessary.
Some Town, YY 12345 Phone: (111) 222-3333 Fax: (111) 222-4444
Page: 9