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Treatment Plan & Progress Note
I will upload all forms as well as the previous assignment you helped me with. I will also add the grading rubric. Please reach out with any questions.
The purpose of this assignment is to help you practice completing a treatment plan and progress notes. Your treatment plan should cover the areas that we discuss in class and you will use the biopsychosocial assessment done in a previous assignment as a guide and the first part of a complete packet on the participant. The progress note should reflect your intake session. You may need to integrate information to complete the treatment plan. Remember this is a fictitious participant.
STEP 1: Read case study
Read the following case study. You will use this to complete your assignment.
Ana is a 17 year old Latina female that is five months into her pregnancy. Ana has long straight dark hair and deep brown eyes. She was diagnosed with Type II diabetes that doctors tell her comes from a poor diet and being extremely overweight. She has been told her medical condition is reversible if she improves her eating habits and loses 100 lbs. Her pregnancy has been tough and most days she reports being extremely fatigued and exhausted. Ana has low self-esteem and believes her diabetes just reinforces “she is broken”.
Ana, at age three, entered foster care on the ground of abandonment after her mother died of a drug overdose and her father ran off. Her aunt agreed to raise Ana but she was removed again within months of her arrival because her aunt was caught using methamphetamines. Following two AZ non-permanent placements within foster care (one home was too crowded and the other family moved out of State), Ana was placed into a foster home of Liz and Aaron Goldman. Both foster parents were White and lived in a middle class neighborhood. Ana recalls asking her foster parents “Why don’t people at church look like me?” and “Why do I look different then everybody else?” Liz would avoid the questions because she was unsure of how to discuss and talk about race with Ana and instead told her “In God’s eyes everybody looks the same”. Ana was told by her social worker that Ana’s family of origin had strong ties to the Christian faith and she was baptized Catholic. Ana eventually left Liz and Aaron for a group home (her fourth placement). Liz and Aaron told her they wanted to adopt and foster another baby but Ana knows the real truth–she never resonated with their faith. That’s how she found Father Jordan Burrough. He was Catholic and there was something about his teachings and personality that made her feel “at home” and reminds her of her biological parents.
Ana states she is working on getting more sleep on a regular basis (living homeless didn’t allow for her to feel safe enough to sleep), eating right and taking a nap every day to improve her overall health. She says she is also wanting to eat a more healthy balanced diet (which she could not do living under the freeway) and to be more physically active. Ana also wants to complete her GED. She wants to go to college and study something that has to do with health. She dreams of becoming a Doctor and having a family and being married at some point in her life. She wants to be self-sufficient and independent and not rely on others for support.
Ana’s first language is English. She was born and raised in AZ but believes both her parents were undocumented people that may have overstayed their work visa’s after she was born. The social worker mentioned once that her parents endured all kinds of pre-migration traumatic experiences. Her mother’s oldest sister was murdered in El Salvador. Her parents immigrated to the US for economic reasons and also because her father’s sister was already here in AZ. She was told by the social worker her parents left behind an entire family when they came to the US and that her parents could never go home again without the fear of prosecution.
Complete a treatment plan and progress note on the above case study.
Use only the Treatment Plan and Progress Note/Soap Note
form provided to complete your assignment.
Be sure to be strengths–based and to use the person in the environment perspective for your treatment plan and progress note. Remember to work within your skill set and capabilities and your current role as the client’s social worker. Social workers look to basic needs being met first and the client will always be the one whom directs their care and determines their goals.
With this being a non-live participant, some information may be missing. You may need to make some assumptions and provide additional information and details that allow you to complete the forms. Please keep in mind that any additional details must be clearly stated and clearly made part of the assessment and treatment plan. Clarifying statement…in live situations we never make assumptions with our participants/clients but rather make assessments. Assumptions are only being used in the learning environment to enable you to complete a full and complete packet for this client.