Social Work Encounter Documentation Template

Client Information

• Name: Marcus James Vance
• Date of Birth: 14/08/1968
• Date of Consultation: 24/10/2023

Referral Source

• Dr. Sarah Lin, Respiratory Medicine Department, Royal Prince Alfred Hospital
• Referred for psychosocial assessment, NDIS navigation, and housing instability support following a recent inpatient admission for an acute exacerbation of COPD.

Presenting Issue

• Experiencing severe financial distress and impending eviction due to rental arrears after losing casual employment. Reports difficulty affording prescribed medications and managing activities of daily living (ADLs) independently due to declining mobility and exertional dyspnoea.

Social History

• Lives alone in a private second-floor walk-up flat in Marrickville with no lift access. Divorced for 8 years; estranged from two adult children. Limited local social support network, relying primarily on a neighbour for grocery shopping.
• Completed Year 10 education. Worked as a casual warehouse storeman until 3 months ago when respiratory symptoms prevented manual labour. Currently receiving JobSeeker Payment; struggling with utility bills and $1,800 in rental arrears.
• History of mild depression and generalised anxiety disorder, currently treated with sertraline (Zoloft®) 50 mg PO OD. Ex-smoker (ceased 6 months ago, 40 pack-year Hx). Denies current ETOH misuse or illicit substance use. No reported Hx of domestic abuse or acute trauma.

Medical History

• GOLD Stage III COPD, T2DM, and hypertension. Prescribed tiotropium (Spiriva®) 18 mcg INH OD, salbutamol (Ventolin®) 100 mcg INH PRN, and metformin (Diabex®) 1,000 mg PO BD. Exertional SOB severely limits ability to climb stairs to his flat, resulting in social isolation.
• Rationing inhalers due to cost. Lacks private transport and finds public transport physically taxing, leading to missed outpatient clinic appointments.

Assessment

• 55yo male facing acute housing insecurity and financial hardship secondary to chronic illness progression and loss of income. Key psychosocial stressors include unsuitable housing (stairs), social isolation, and financial strain impacting medication adherence. Strengths include high health literacy, insight into condition, and motivation to engage with support services.
• Demonstrates adaptive coping via help-seeking behaviour and smoking cessation, though currently overwhelmed by administrative barriers to accessing welfare support.
• Low risk of self-harm or suicide (denies suicidal ideation, plan, or intent). Moderate risk of unintentional self-neglect and hospital readmission if housing and medication access are not stabilised.

Interventions

• Provided supportive counselling and validation regarding recent functional decline and role loss. Assisted client in initiating a Disability Support Pension (DSP) application via Centrelink and issued emergency food vouchers.
• Provided psychoeducation on the Pharmaceutical Benefits Scheme (PBS) Safety Net, NSW Housing priority transfer pathways, and basic cognitive behavioural strategies for managing dyspnoea-related anxiety.

Plan

• Immediate objective: Stabilise current tenancy and secure emergency financial relief. Long-term objective: Transition to ground-floor social housing and establish sustainable income via DSP.
• Referred to St Vincent de Paul Society for emergency utility and rental arrears assistance. Referred to local Community Transport for future medical appointments.
• Will draft a clinical support letter for Housing NSW detailing medical necessity for ground-floor accommodation, and contact the real estate agent (with client consent) to negotiate a temporary payment plan.
• Telehealth check-in scheduled for 31/10/2023 at 10:00 to review DSP application progress and tenancy status.
• Obtain medical evidence form from Dr. Lin to finalise DSP submission; submit referral to My Aged Care / NDIS (pending age/eligibility review) for domestic assistance.