1023-8           CLIENT NOTE (CLNO) SAMPLES DURING DISCOVERY

Sample 1 – Introductory Discovery Meeting

Date/Duration: 08.20.12, 45 min.
Activity: Introductory Discovery Meeting
People Present: Client (name), CM (name), DS (name)
Description: Introduced (client name) to (DS name). Reviewed Discovery Orientation. (Client name) asked questions about the use of photos and DS explained use of the Portfolio. (CM name) reviewed the Family Network and Weekly Routines/Calendar. (DS name) provided variety of options for scheduling Discovery activities that work with the client’s family obligations. (DS name) and (client name) scheduled the first 3 Discovery visits/activities. (Client name) requested, and DS agreed to meet for 1.5 hours/3x per week for the first week, 10-11:30 AM, T, W, F. (Client name) requested that her mother, as her Natural Support attend the first 2 visits with the DS. (DS name) agreed. (CM name) provided (DS name) the client’s Discovery file, including current ROIs. Signed DHSS Media release form for purpose of photography.
Action Plan: (DS name) and (client name) will meet 08.21.12 to begin initial Discovery. CM to contact DS on 08.24.12 to update status of initial Discovery visits. CM to confirm FST meeting scheduled 08.27.12 to introduce DS to the FST.

Sample 2 – Discovery Update (initial visits, preparing for Discovery activities)

Date: 08.24.12
Activity: Summary of Discovery (phone)
Description: (DS name) reported that she had completed the following: 1. Completed the Profile Part I, 2. Prepared client for upcoming FST meeting, 3. Created list of 2 observations to be carried out in the community, 4. Identified 2 FST members to interview, 5. Scheduled upcoming visits (next week: 08.27.12 – FST meeting, M, 2–3 PM, 08.28.12, T, 10–11 AM, 08.31.12, F, 2 –3 PM). Scheduled 2 FST member interviews (next week: 08.29.12, W, 12–1 PM and 08.31.12, F, 4–5 PM). (Client name) noted need for child care to engage in Discovery observations. (DS name) reported that (client name) is frequently talking about significant problems with unexpected fatigue, both in past and current.
Action Plan: Conduct FST meeting on 08.27.12, ensure ROIs current. Add both child care and sleep issues to discuss as part of FST agenda with (client’s name) permission.

Sample 3 – Discovery Update (approaching conclusion of Discovery)

Date: 09.17.12
Activity: Summary of Discovery (phone)
Description: (DS name) reported that she had completed the majority of Discovery interviews and observations with exception of the novel activity. (DS name) shared that (client name) has expressed hesitancy with being observed in an activity that is unfamiliar due to fear of feeling embarrassed or inadequate. Discussed with the DS whether it would help to have an FST member talk with (client name). After some discussion, (CM name) agreed to contact client to ask if she’s willing to have a joint meeting with the DS and her counselor to address her fears, and come up with an observational activity that is comfortable for her, yet new, and unfamiliar. (DS name) also agreed to not take any photos or notes during the observation in order to lessen (client’s name) anxiety. (CM name) informed (DS name) that he is in the process of planning the FST meeting to review Profile Part II in preparation for the EPM. (DS name) provided best dates, times to carry out the meeting, and confirmed that Profile Part II will be complete by 10.05.12, and the EPM could be scheduled the week of 10.15.12.
Action Plan: Contact (client name) to offer a meeting with counselor and DS. Coordinate and schedule FST meeting to review Profile Part II by 10.08.12, and arrange EPM to be conducted no later than 10.22.12.