Saint Petersburg College Mental Health Contact Notes Just condense the attached contact notes and make it realistic. Please Create contact notes for 3-4 se

Saint Petersburg College Mental Health Contact Notes Just condense the attached contact notes and make it realistic. Please Create contact notes for 3-4 separate occasions of contact. Just write the notes as if you were there, conducting interviews or providing treatment. It would be okay to write the notes as if you are the doctor or from a case manager perspective. In this project, I will be assigning each group a vignette/video (in your Group Discussion) of a client intake interview. The group will follow this fictitious client from intake to discharge. There may be additional issues with the client not addressed in the video. Groups may be creative in identifying additional issues (i.e., diabetes, etc.) and will need to decide on names, addresses, etc Here is the link to the video assigned to this case According to the text, contact notes shouldn’t be more than 6-7 sentences. Contact notes are just meant to summarize each meeting or phone call with the client. The example was just meant to emphasize what needs to be included in each contact note. The notes shouldn’t actually be broken down into sections like that. Attached are documents from other completed tasks for this assignment to assist with the contact notes. Intake Assessment
Client Name:
Agency/ Interviewer: Group 4
Date of Birth: _________________
Date of Assessment: __November 3, 2019__
1. Main problems/ Concerns: _Anger – states will punch non-living objects. _______________
Drug/Substance Abuse – Smokes a lot of Marijuana and has begun to snort Xanax____________
Pride / Inflexibility – has lost friendships due her way is the only right way_________________
Past Mental Health: Patient states she has seen counseling three times during her high school
years. Patient states does not follow through with counseling
___________________________________ Social
Family Relationships:
Mother: Is not close to her mother, not a good relationship, does not communicate much with
her. Patient states mother is eccentric. Patient moved out at 16 when she got pregnant with her
first child. Her mother told her to terminate the pregnancy or get out.
Father: Deceased. Died of a stroke. Did not have a relationship with him. Patient states she was
told father physically abused her. She does not remember it. ____________________________
Kids: _2 Children -I 1 daughter in 2nd grade with behavioral problems. She acts out and is a bully
to other children. 1 son in Kindergarten who has anger issues with the patient.
Siblings: _2 sisters one older and one younger. Patient closer to her older sister and speaks to her
regularly almost every day. Patients younger sister not as close but does talk to her occasionally.
Normally one every other week or so. Older sister is aware of counseling younger sister has not
been told yet but patient will tell her next times she talks to her.___________________________
Friends: _Has one or two close friends. Currently is living with one of them. The other friend she
speaks to every other day.
Support: Friends encouraged her to seek counseling and willing to support her. The friends feel
that working with a counselor may help with the anger and instability in her life to keep a safe
home for her and her children instead of sleeping on friends’ couches. She needs to get stability
for her children before she losses her children________________________________________
Educational: Patient is currently working on her GED. While she was in elementary school, she
had OK grades and was very active with school activities. In middle school is when the anger
started but still was staying involved with the clubs. In high school she did not take it seriously,
teachers were always on her case. Was expelled in the 11th grade.
Occupation: Her first job was retail and was fired for not showing up. Her 2nd job was also retail
and got into an argument with a customer so quit. Her 3rd job which is her current job is in a
warehouse that is meaningless work and considers it an OK job.
Finances: She has a hard time paying her bills and lives with friends with her children.
Relationship Risk Factors: She is currently not is a romantic relationship. Her past boyfriend got
annoyed by her demands._________________________________________________________
___________________________________ Medical
PCP: She using the local health department for her primary care services for both her and her
children. She has chosen not to follow up with applying for medical assistance because it is too
time consuming_______________________________________________________________
Current Medical Conditions: Asthma, car accident leg shattered and now has a limp. Has had
surgery to correct it. Sprained RT wrist- Dominant hand does not bother her anymore. She also
have high blood pressure that she does not follow up with because she does not go to the doctor.
Current Medications: She should be taking medical for her asthma and high blood pressure but
chooses not to follow up with the doctor to get the refills needed. ______________________
Medical Exam:
Motor Activity: The only restriction is the limp that does not affect her daily activities.
Manner: Her manner is appropriate, guarded and defensive during the interview process.
Speech: The speech is normal and clear.
Mood: Her mood appears depressed, irritable and anxious. The fatigue she states is most likely
due to the depression.
Affect: The affect is flat.
Sleep: The patient states that her sleep is poor and has a moderate level 0f insomnia.
Appetite: She states she has a good appetite and has gained weight.
Thought process: She reports that it is illogical and distractible.
Perception/hallucinations: She reports depersonalization.
Judgement: She appears impulsive, immature.
Insight: Aware of current disorder and understands personal role in problems.
Sensorium: Patient appears alert.
Memory: Patient appears intact.
Intelligence: Unable to establish.
___________________________________ Mental
Suicide/ Homicide Evaluation: Patient states she does not have any intentions to herself or
Mental Status Exam: They have diagnosed her with depression and anxiety and think she may
have bipolar but does not follow through with doctors to get the evaluations and medications
needed to help her.___________________________________________________________
Interviewer Summary: After interviewing her and determining that she needs to see a
psychologist to get on medicine in addition to weekly counseling sessions she is in agreement to
get the assistance she needs to stabilize her employment history, living arrangements and caring
for her children.________________________________________________________________
Substance Abuse: Patient currently smokes Marijuana daily several times a day even while
working. She states her co-workers are aware of her behavior. She has also started snorting
Xanax on the weekends. ______________________________________________________
Client Summary: Patient would like to work on her anger issues and to become drug free.
Clinical Summary: The Pshycologist has prescribed Risperidone assist with the bipolar diagnosis
and Carbatrol for the mood stabilizing. She is to follow up with counseling weekly and the
psycologist bi-weekly she is stabilized with the medication. _____________________________
Clearwater Behavioral Health Outpatient Services
Contact Notes
Client: Renee Mendez
MRN # 03876
DOB 05/09/1986
The focus of the Interview
Renee Mendez went to Dr. Todd’s office to express her need to change gears and create romantic
relationships. Renee Mendez, in the video, acts as a counseling client and reveals symptoms of
inflexible thinking, anger, and substance abuse, which ruined her social relationships in the past.
Dr. Todd asked the types of friends Mendez had before. Mendez responded that she had many
friends whom she visited and exposed her to substance abuse. Mendez created many friends who
accommodated her when she lacked money to pay rent. Mendez moved regularly seeking new
friends who could assist her, and in some places, she found stronger friends who sacrificed a lot
for her well-being.
Your Assessment
Renee Mendez appeared depressed and required medical help. The description of her life in the
past confirmed that she was not strong enough and required therapeutic interventions. Most of her
friends harassed Mendez, and this client remained depressed always as she moved from one
household to another seeking new friends who could accommodate her. Dr. Todd asked how many
close friends the client identified in her social relationships. Mendez had encountered only two
influential friends who could help her handle life challenges. Mendez had boyfriends but was
unhappy with her duties towards her boyfriends. In the past, she witnessed an accident and
sometimes experienced pain when performing physical tasks. The sustained car accident ruined
the mental and physical health of Renee Mendez (Grande & Mendez, 2016, 02:39). Renee Mendez
was sometimes under the influence of Cocaine, and Dr. Todd realized his condition was worse
than he expected. Mendez could not be involved in an accident if she was not drunk. Renee does
not take medications to relieve pain and reported to Dr. Todd that the year of the accident, she
underwent surgery and advised to avoid heavy physical tasks. After the accident, the wrist and
hands of Renee Mendez have been painful whenever she carries heavy objects.
After the accident, Renee Mendez began abusing Marijuana to comfort herself. She felt her mental
health was ruined and remained hopeless in life. The client explained that the influence of
Marijuana increased her hostility and used to fight with anybody they argued with. In the past,
Mendez was treated for mental health conditions (Grande & Mendez, 2016). The client was
suffering from ‘Rhea’ which was treated by a psychiatrist and other mental health professionals.
In her psychiatric treatment, Renee underwent PTSD and was told by health professionals all
mental issues affecting her behavior and general health. Renee Mendez was annoyed to realize
that she was a victim of mental illness and remained impressed until the day he was referred to
Dr. Todd. Other than mental health issues, family challenges affected Mendez
Client: Renee Mendez
MRN # 03876
DOB 05/09/1986
while in school. She explained in the video that she visited a school counselor severally to discuss
her grades and behavior. At home, Mendez was exposed to a violent environment. Domestic
violence created fear in her and affected her level of concentration in class.
The Resolution
Dr. Todd was to offer the best therapeutic intervention to handle her mental health problems and family
issues. Dr. Todd was focused on assessing the hand of the client after the client explained the
difficulties she faced since she engaged in an accident. The accident weakened her body and impaired
her mental health. Renee remains depressed because of the accident experiences. Interventions by Dr.
Todd were provided after the medical history of the client was reviewed. Dr. Todd recommended his
client on a therapeutic program. In the program, Renee was referred to Rhea Medical Center, where
she was exposed to recovery programs that resolved her mental health issues. While at Rhea Medical
Center, the client was provided with supportive housing (Christopher, 2019). Outpatient therapy was
not effective to the client because she was affected by several issues ranging from mental health to
family issues. Therefore, Mendez was recommended for psychiatric medication management. Such
programs will ensure the problems of social relationships are resolved and the best future practices
Mendez benefited from meeting a therapist. She was advised on a healthy lifestyle. Dr. Todd advised
her on ways of managing past experiences to avoid depression. Mendez was depressed whenever she
remembered the accident she encountered while drunk. At Rhea Medical Center, medications were
provided to relieve pain in Mendez’s wrist and hands. Before she attended an appointment with Dr.
Todd, the lady complained of regular pain in joints and wrist. Dr. Todd advised Mendez to ignore
weaker friends who might expose her to dangerous situations. She was advised to support friendship
with people who understood her state of health and were ready to offer help when necessary (Grande
& Mendez, 2016). For instance, strong friends to Mendez could be those who freely contribute funds
to cater for her medical bills and therapeutic programs. Weaker friends are dangerous and could
influence Mendez to continue abusing drugs like Marijuana and Cocaine. Dr. Todd emphasized on few
but beneficial friends. From the assessment, Dr. Todd realized that Mendez ruined her health through
drug abuse. Abusing Cocaine was dangerous to Mendez’s health. The counselor after assessment
recommended the best therapeutic interventions which could help Renee Mendez quit from the
deviance behavior of abusing drugs. She was advised to stop getting annoyed when approached by
friends of the opposite gender. Instead, Renee Mendez was guided on how to associate with a boyfriend
healthily. The day Mendez attended the appointment with a counselor marked the end of abusing drugs.
She was convinced of the negativity of drugs and promised to quit from that deviance behavior. More
so, Renee Mendez promised to remain consistent with the therapeutic programs recommended by Dr.
The questions asked by the counselor during the assessment helped confirm whether what the client
was explaining was followed by the counselor. Dr. Todd asked critical questions, which helped get the
whole picture on family and mental health issues affecting Renee Mendez. Mendez considered the
responses from clients to help recommend the effective therapeutic program. Referring Mendez to get
better medical care to heal her mental issues at Rhea Mental Health Center was amongst the
intervention, which positively impacted her health (Christopher, 2019). Renee was not afraid to discuss
all of her mental problems to the counselor and ensured the best resolution was realized to cater to her
mental health. Dr. Todd asked a few questions and reframed all client statements to gather additional
Client: Renee Mendez
MRN # 03876
DOB 05/09/1986
information on social, emotional, and physical issues affecting the client. In future intake assessment
projects, Dr. Todd should include the case of Mendez because their interaction was excellent and helped
get the best resolution for mental health issues.
Reasons for the next contact
The next contact will be held on 12th December 2019. The next contact will be an opportunity for
Dr. Todd and Renee Mendez to discuss if the recommended therapeutic interventions are
improving her health. Also, Dr. Todd, in the next contact will examine the effectiveness of
medications administered to his client at Rhea Mental Health Center. Dr. Todd believed that his
client will get the right medications and was eager to have the next contact to confirm the treatment
services. A variety of therapies are offered at Rhea Mental Health Center to monitor the health
conditions of patients (Christopher, 2019). Patients with mental illnesses benefit from the services
offered at Rhea.
Christopher, S. (2019). Rhea Mental Health Center – Dayton. Retrieved from

Grande, T. L., & Mendez R. (2016). Intake and Assessment Role-Play Part 3 – Social,
Medical, and Mental Health History. Retrieved from

Clearwater Behavioral Health Outpatient Services
New Referral or Inquiry
Client Mendez Sex F DOB 5/9/86
MRN #_03876_
Social Security # ***-**-5555
Address 1453 Wildwood Street,
Home Telephone 444-444-444
Employer Courts Warehouse
Referral Friend
Chief complaint and description of the problem
A client called today to discuss her mental illness. There was a friend of Mendez who referred her to
Dr. Todd Grande. They discussed the social relationships and the effects of many friends in the life
of a person. The client described her medical history and talked about the critical mental issues
affecting the client in her early 20s.
Previous evaluation, services or treatment Counseling during High School
Inquiry by
Date of inquiry 10/30/2019
Disposition Referred to Dr. Todd Grande for intake 11/03/2019
Verification sent yes (10/30/2019)
Clearwater Behavioral Health Outpatient Services
Verification of Appointment
Date 10/30/2019
Dear Mrs. Mendez
This letter is intended to remind you about your upcoming appointment scheduled with Dr.
Todd Grande:
Date: 11/03/2019
Time:11:00 AM
Location: Clearwater Behavioral Health Outpatient Services
11333 US 19 North, Clearwater FL 33444
Phone # 727-888-8888
Please contact the office and give any updated information concerning the scheduled
appointment. Please arrive 15 minutes before your scheduled time to complete the new client
paperwork or you can complete it on our website at
We look forward to seeing you.
Clearwater Behavioral Health Outpatient Services
Peer Support Services Referral Form
Renee Mendez_____________
__23 Curlew Road, Largo, FL__
Case Manager:
Customer Phone
Current Living Status:
( ) Living Independently
( ) Living with Family
(X ) Living with Others
( ) Homeless ( ) Other
Health Status:
Health Status Notes:
High blood pressure, Asthma_,
and limp due to car_________
accident. HX of_____________
Customer must meet
all of the following
criteria in order to be
eligible for Peer
Support Services:
(x) 18 years of age w/ one or
more serious challenges to
(x ) Moderate to severe
functional impairments that
interferes with, or limits, role
performance in at least one of
the following areas:
(x ) Educational (x ) Social
( ) Vocational
( ) Self-maintenance
Does customer
agree to Peer
Support Services?
Reason for Referral:
__Ms. Mendez has a history of anger issues and social problems. Ms. Mendez also
currently smokes marijuana heavily. She recently started snorting Xanax. Ms. Mendez
states that she has only a couple of friends. Admits that she is hard to get through to
and this has caused her to lose friends in the past. Client admits that she wants to__
lower her incidence of anger and work on her inflexibility and her pride, which she_
also admits to having.__________________________________________________
Referral Source:
Phone Number:
Peer Signature:
__Clearwater Behavioral Health Outpatient Services___________________________
Agency Number:
Date of Birth:
Case Manager
Phone Number:
( ) No Health Concerns
( X) Serious Health condition
__Community Health Center
(x ) Yes
( ) No
(x ) Accepted ( ) Not Accepted

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