MH – Social Work Report



Patient name: [textarea cols=40 rows=1 default=""]
Sex: [select value="Male|Female"]
Date of Birth: [text default=""]
Marital Status: [select value="Unmarried|Married|Divorced|Separated|Widow|Widower"]


[checkbox name="income" value="Income problems identified:"] [conditional field="income" condition="(income).is('Income problems identified:')"] [checkbox value="the patient has experienced fluctuations in income due to inconsistent employment.|the patient has no source of income|the patient has reported difficulty in maintaining employment due to mental health symptoms.|the patient's mental health condition has led to long periods of unemployment.|the patient relies heavily on financial support from family or friends, which may not be sustainable.|the patient has lost income opportunities due to hospitalizations or treatment requirements.|the patient's medications or treatments create additional financial burdens.|the patient struggles to manage money and budget effectively, exacerbating their financial situation.|due to the patient's mental health symptoms, they often make impulsive or ill-advised financial decisions.|the patient has been taken advantage of financially due to their mental health condition.|the patient lacks the necessary skills or resources to advocate for financial assistance or benefits they may be entitled to."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="housing" value="Housing concerns identified:"] [conditional field="housing" condition="(housing).is('Housing concerns identified:')"] [checkbox value="the patient has expressed concerns about potential eviction or loss of their current residence.|the patient faces a risk of being evicted due to behavioural issues or disturbances.|the patient has faced frequent evictions in the past, destabilizing their housing situation.|the patient has frequent relocations, making it challenging to maintain a stable living environment.|the patient's current residence is unsuitable due to factors such as noise, location, or lack of necessary amenities.|the patient's current housing is inadequate or unsafe, leading to potential health or safety risks.|the patient has expressed feelings of isolation or lack of community in their current residence.|the patient has a history of homelessness or has been at risk of becoming homeless.|housing options or support for the patient's specific mental health needs are limited or lacking.|the patient has reported disputes or conflicts with neighbors or housing management that exacerbate their mental health symptoms."]
[textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="employment" value="Employment concerns identified:"] [conditional field="employment" condition="(employment).is('Employment concerns identified:')"] [checkbox value="the patient described a consistent pattern of unemployment or underemployment.|the patient often faces challenges in maintaining long-term employment due to personal or external factors.|the patient has expressed concerns about job security and potential layoffs.|the patient has shown a history of job-hopping, making it difficult to maintain stable employment.|the patient is unable to hold a job."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="spending" value="Impulsive spending problems identified:"] [conditional field="spending" condition="(spending).is('Impulsive spending problems identified:')"] [checkbox value="the patient acknowledged his/her impulsive spending and has begun to develop a plan to help cope with this problem.|the patient described a pattern of impulsive spending without considering the eventual financial consequences.|the patient's impulsive spending often occurs in relation to psychotic/manic episodes or drug-affected states.|the patient tends to make impromptu purchases without planning for or considering the financial consequences.|the patient has shown a consistent history of impulsive spending, leading to significant financial strain."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="budgeting" value="Budgeting problems identified:"] [conditional field="budgeting" condition="(budgeting).is('Budgeting problems identified:')"] [checkbox value="the patient described a long-term lack of discipline and money management leading to a failure to budget for basic responsibilities.|the patient described that his/her financial information is poorly organized, leading to unpaid bills and increased financial liability.|the patient has never established a budget with guidelines or savings goals, resulting in irregular payment of bills.|the patient has consistently failed to manage or track expenses, leading to severe financial deficits."] [textarea cols=70 rows=10 default="details"][/conditional]

[checkbox name="entitlements" value="Monetary entitlements problems identified:"] [conditional field="entitlements" condition="(entitlements).is('Monetary entitlements problems identified:')"] [checkbox value="the patient described a history of not applying for or accessing available welfare benefits.|the patient displayed a lack of knowledge of available monetary entitlements or other welfare benefits.|the patient has been reluctant to access monetary entitlements or other welfare benefits due to perceived stigma regarding these resources.|the patient has consistently missed opportunities to access monetary benefits, leading to financial strain."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="credit" value="Credit history problems identified:"] [conditional field="credit" condition="(credit).is('Credit history problems identified:')"] [checkbox value="however, the patient has taken proactive steps recently to improve their credit history.|the patient's mental health symptoms have led to missed payments or defaults.|the patient has a pattern of unpaid bills and outstanding debts due to financial mismanagement related to their mental health condition.|the patient has been denied loans or credit opportunities due to their poor credit score.|due to periods of hospitalization or treatment, the patient has been unable to manage their credit obligations.|impulsive or ill-advised financial decisions due to mental health symptoms have further worsened the patient's credit.|the patient lacks knowledge or resources on how to repair or maintain a good credit history.|the patient's medications or treatments create additional financial burdens that impact their ability to manage credit.|the patient has faced higher interest rates or unfavorable financial terms due to their credit history."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="debt" value="Debt problems identified:"] [conditional field="debt" condition="(debt).is('Debt problems identified:')"] [checkbox value="the patient's mental health symptoms have contributed to the accumulation of significant debts.|due to financial mismanagement linked to their mental health condition, the patient has a pattern of not settling bills and accruing debt.|as a result of their debt history, the patient has faced challenges in securing loans or other financial opportunities.|periods of hospitalization or treatment have resulted in the patient incurring further debts.|mental health-triggered impulsive or misguided purchases have increased the patient's debt.|the patient is unaware of or lacks resources on strategies to effectively manage and reduce debt.|the cost of the patient's medications or treatments creates added financial pressures, exacerbating their debt issues.|because of their debt, the patient is subjected to higher interest rates or unfavorable financial conditions."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="fines" value="Fines-related problems identified:"]
[conditional field="fines" condition="(fines).is('Fines-related problems identified:')"] [checkbox value="the patient's mental health symptoms have led to behaviours resulting in fines.|due to misunderstandings or forgetfulness related to their mental health condition, the patient frequently incurs fines.|the patient has a history of neglecting or being unaware of notifications about fines, causing them to accumulate.|periods of hospitalization or treatment have prevented the patient from addressing fines in a timely manner.|impulsive actions or decisions, influenced by mental health symptoms, have led to the patient receiving fines.|the patient is unaware of or lacks resources on how to manage and clear outstanding fines.|the patient's financial constraints, partly due to medication or treatment costs, make it challenging to pay off fines.|due to their history of unpaid fines, the patient faces added penalties or legal consequences."]
[textarea cols=70 rows=10 default="details"] [/conditional]


[checkbox name="financialIntervention" value="Discussion of finances initiated:"] [conditional field="financialIntervention" condition="(financialIntervention).is('Discussion of finances initiated:')"] [checkbox value="however, the patient has little understanding of their pattern of financial problems, and further guidance is needed.|the patient was asked to provide a detailed account of their financial history and related challenges.|the patient was aided in recognizing and comprehending the pattern of their financial issues.|the patient began to associate their financial difficulties with the symptoms of their severe and persistent mental illness.|positive reinforcement was given to the patient for their growing insight into their financial challenges and its relationship with their mental health.|the patient demonstrated a notable increase in understanding their financial difficulties, and further constructive feedback was provided."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="financialBlameIntervention" value="Intervention for feelings of blame initiated:"] [conditional field="financialBlameIntervention" condition="(financialBlameIntervention).is('Intervention for feelings of blame initiated:')"] [checkbox value="however, the patient continues to harbour strong feelings of self-blame regarding financial problems, requiring more therapeutic support.|the patient was assisted in acknowledging feelings of blame and guilt associated with their financial challenges.|therapeutic conversations were initiated to help the patient differentiate between personal responsibility and uncontrollable factors.|the patient was provided tools and strategies to address and manage feelings of self-blame regarding financial issues.|positive reinforcement was given to the patient for their efforts to confront and manage feelings of blame.|the patient demonstrated a decreased sense of self-blame and an increased ability to approach financial problems with self-compassion and understanding."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="positiveFinancialPracticesIntervention" value="Intervention for positive financial practices initiated:"] [conditional field="positiveFinancialPracticesIntervention" condition="(positiveFinancialPracticesIntervention).is('Intervention for positive financial practices initiated:')"] [checkbox value="however, the patient initially struggled to identify any positive financial habits they possess, necessitating guidance and reflection.|the patient was assisted in recounting past instances where they exhibited sound financial decisions.|therapeutic discussions were initiated to highlight the significance of their positive financial behaviours, no matter how minor they may seem.|the patient was provided with affirmation and feedback on their positive financial practices, bolstering their confidence.|the patient started incorporating more of these positive financial habits into their daily life, demonstrating growth and learning.|the patient consistently demonstrated an ability to recognize, maintain, and expand upon their positive financial practices, indicating significant progress."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="unhelpfulFinancialPracticesIntervention" value="Intervention for unhelpful financial practices initiated:"] [conditional field="unhelpfulFinancialPracticesIntervention" condition="(unhelpfulFinancialPracticesIntervention).is('Intervention for unhelpful financial practices initiated:')"] [checkbox value="however, the patient initially displayed resistance or unawareness of any unhelpful financial habits they possess.|the patient was assisted in recounting and acknowledging instances where they made unsound financial decisions.|through therapeutic discussions, the patient began to recognize the negative impact of certain financial behaviors on their overall well-being.|the patient started to display motivation to address and change these unhelpful financial practices.|with consistent guidance, the patient began developing strategies to mitigate and replace unhelpful financial habits.|the patient consistently demonstrated an ability to identify, reduce, and avoid their unhelpful financial practices, showing significant progress towards financial responsibility."] [textarea cols=70 rows=10 default="details"]

[checkbox name="dysfunctionalSpendingPatternsIntervention" value="Intervention for dysfunctional spending patterns initiated:"] [conditional field="dysfunctionalSpendingPatternsIntervention" condition="(dysfunctionalSpendingPatternsIntervention).is('Intervention for dysfunctional spending patterns initiated:')"] [checkbox value="however, the patient initially displayed denial or unawareness of any dysfunctional spending habits.|the patient was assisted in reflecting upon and acknowledging patterns of overspending or impulse buying.|through therapeutic discussions, the patient began to discern the triggers and underlying emotions tied to their spending behaviors.|the patient displayed increased motivation to understand and rectify these dysfunctional spending habits.|with guided support, the patient commenced planning and implementing strategies to counteract and modify these spending patterns.|the patient consistently showcased an ability to recognize, control, and modify their dysfunctional spending behaviors, leading to more stable financial habits."] [textarea cols=70 rows=10 default="details"]

[checkbox name="financialObligationsIntervention" value="Intervention for identifying financial obligations initiated:"] [conditional field="financialObligationsIntervention" condition="(financialObligationsIntervention).is('Intervention for identifying financial obligations initiated:')"] [checkbox value="however, the patient initially displayed little awareness or understanding of their existing financial obligations.|the patient was provided with resources and tools to list and categorize their monthly bills, debts, and other financial commitments.|through discussions and assessments, the patient began to recognize the full scope of their financial responsibilities.|the patient has started to prioritize and address these obligations in a systematic manner.|with ongoing support, the patient developed a strategy to meet these obligations consistently.|the patient has shown a consistent pattern of addressing and managing their financial obligations, demonstrating improved financial responsibility."] [textarea cols=70 rows=10 default="details"]

[checkbox name="mentalIllnessFinancialEducation" value="Education on mental illness and its effects on finances initiated:"] [conditional field="mentalIllnessFinancialEducation" condition="(mentalIllnessFinancialEducation).is('Education on mental illness and its effects on finances initiated:')"] [checkbox value="however, the patient initially displayed little awareness or understanding of how their mental illness impacts their financial behaviors.|the patient was provided with materials and discussions centered on the relationship between mental health symptoms and financial challenges.|through continuous sessions, the patient began to recognize specific patterns and triggers related to their spending during episodes of mental distress.|the patient was introduced to coping strategies and techniques to mitigate the financial impact of their symptoms.|with ongoing guidance, the patient began implementing these strategies, leading to fewer impulsive financial decisions during periods of mental distress.|the patient has shown a consistent pattern of understanding and managing the financial implications of their mental health, demonstrating improved financial resilience."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="trusteeDiscussion" value="Discussion on trustee benefits initiated:"] [conditional field="trusteeDiscussion" condition="(trusteeDiscussion).is('Discussion on trustee benefits initiated:')"] [checkbox value="the patient showed initial resistance or apprehension about the idea of having a trustee.|the patient was provided with an overview of how a trustee could assist in managing their finances and protecting their assets.|the patient was given examples of situations where a trustee has successfully aided individuals in similar circumstances.|through continuous discussions, the patient began to express interest and openness to the concept of a trustee.|the patient met with potential trustees to understand the process and responsibilities better.|with guidance, the patient decided to appoint a trustee and has begun to see improvements in their financial management and overall peace of mind."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="trusteeCoordination" value="Trustee coordination efforts underway:"] [conditional field="trusteeCoordination" condition="(trusteeCoordination).is('Trustee coordination efforts underway:')"] [checkbox value="initial steps were taken to understand the patient's needs and preferences for a trustee.|informational resources were provided to the patient about selecting a trustworthy and competent trustee.|the patient was assisted in setting up meetings or interviews with potential trustees.|the patient was supported in evaluating and comparing the capabilities and trustworthiness of potential trustee.|with assistance, the patient prepared necessary documentation and formalities to appoint a trustee.|the patient successfully appointed a trustee and a system was established for regular communication and updates on financial matters."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="legalControl" value="Involuntary legal control efforts underway:"] [conditional field="legalControl" condition="(legalControl).is('Involuntary legal control efforts underway:')"] [checkbox value="preliminary discussions were initiated to understand the need for involuntary legal control over the patient's finances.|the team evaluated the patient's financial decision-making capacity and documented concerns.|legal counsel was consulted to understand the process and prerequisites for pursuing involuntary control.|gathered evidence of the patient's inability to manage finances responsibly due to mental illness.|with legal counsel, prepared necessary documentation and filings for pursuing involuntary control.|the legal process for involuntary financial control was initiated.|the court granted involuntary legal control over the patient's finances to a designated trustee and guardian."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="residentialCare" value="Residential care coordination efforts underway:"] [conditional field="residentialCare" condition="(residentialCare).is('Residential care coordination efforts underway:')"] [checkbox value="the patient was placed in a residential care facility to ensure a stable residence regardless of financial management skills.|the patient was supported in accepting the residential care placement, leading to a stable living situation.|the patient has declined the residential care placement and continues to face housing instability due to financial mismanagement; they were further encouraged to reconsider this decision.|the patient was assisted in coordinating placement with family or friends to ensure a stable residence not influenced by financial challenges.|the patient was supported in accepting placement with family or friends, resulting in a more stable living situation.|the patient declined the placement with family or friends and continues to experience housing challenges due to financial issues; further discussions were initiated to revisit this decision."]
[textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="independentLiving" value="Support for independent living provided:"] [conditional field="independentLiving" condition="(independentLiving).is('Support for independent living provided:')"] [checkbox value="the patient was introduced to resources and tools aimed at supporting independent living.|the patient was provided with skills training specific to managing daily tasks and responsibilities in an independent setting.|the patient was connected with community resources to aid in maintaining an independent living situation.|the patient demonstrated improvement in managing the responsibilities of independent living and was given positive feedback.|the patient still struggles with certain aspects of independent living, and additional resources or training sessions were recommended."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="financialReview" value="Financial needs and management reviewed:"] [conditional field="financialReview" condition="(financialReview).is('Financial needs and management reviewed:')"] [checkbox value="the patient was provided an initial overview of their current financial situation and needs.|the patient and author collaboratively identified areas of financial concern and potential solutions.|the patient was educated on key financial management practices suitable for their situation.|the patient demonstrated an increased understanding of their financial needs and has begun to implement recommended practices.|while the patient understands their financial needs, there are still challenges in managing finances, and additional sessions or interventions were recommended."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="govBenefits" value="Application for government benefits initiated:"] [conditional field="govBenefits" condition="(govBenefits).is('Application for government benefits initiated:')"] [checkbox value="the patient was assisted in obtaining and beginning the process of completing forms for government benefits.|the patient has completed all necessary documentation for filing for government benefits, and the documentation was thoroughly reviewed.|despite efforts, the patient's application for government benefits was found to be incomplete, and further assistance was provided to complete these applications."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="budgetEdu" value="Budgeting skills education initiated:"] [conditional field="budgetEdu" condition="(budgetEdu).is('Budgeting skills education initiated:')"] [checkbox value="the patient was introduced to the basic principles of budgeting and financial management.|the patient participated in an education session on budgeting and showed understanding of key concepts.|the patient actively applied learned budgeting techniques in personal finance exercises and received feedback.|despite efforts, the patient still struggles to grasp certain budgeting concepts, and additional targeted education was provided."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="developBudget" value="Budget development process begun:"] [conditional field="developBudget" condition="(developBudget).is('Budget development process begun:')"] [checkbox value="the patient was provided with templates and resources to start creating a personal budget.|the patient started documenting monthly income and expenses as a preliminary step.|the patient, with assistance, drafted a comprehensive budget considering all regular expenses and potential savings.|despite efforts, the patient is finding difficulty in finalizing the budget and needs further guidance and support."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="longTermPlan" value="Long-term financial planning process started:"] [conditional field="longTermPlan" condition="(longTermPlan).is('Long-term financial planning process started:')"] [checkbox value="the patient was introduced to the basic principles of long-term financial planning.|the patient began outlining personal financial goals and milestones for the next 5-10 years.|the patient, with assistance, created a structured long-term financial plan incorporating potential investments, savings, and retirement strategies.|despite efforts, the patient is finding difficulty in finalizing the long-term plan and seeks further guidance and mentoring."] [textarea cols=70 rows=10 default="details"] [/conditional]

[checkbox name="identification" value="Process of obtaining proper identification started:"] [conditional field="identification" condition="(identification).is('Process of obtaining proper identification started:')"] [checkbox value="the patient was guided on the importance and procedures to acquire proper identification.|the patient has collected necessary documentation and is ready to proceed with the application process.|the patient has successfully obtained his/her proper identification.|despite assistance and reminders, the patient is facing challenges or delays in procuring the required identification and requires further support."] [textarea cols=70 rows=10 default="details"] [/conditional]



Patient name:

Date of Birth:
Marital Status:



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.66, 112 form elements, 20 boilerplate words, 1 text boxes, 28 text areas, 54 checkboxes, 2 drop downs, 27 conditionals, 218 total clicks
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