Plaintiff

fu-j ri T2.fiV<

RICHARD W. HAGH!

CLER'x ==r c-:'

UNITED STATES DISTRICT COURT^ „ PH 7 09

SOUTHERN DISTRICT OFOHIO^''

DIVISION 'J,si.

mouther:*; uisr.oHio

E/ E; D:v. CGI.UHHU"

pn.D' l-i- 2:17cv865

vs. CASE NO. ^ *

Judge Watson • COMMISSIONER OF -

SOCIAL SECURITY, iVlAGlSTRATE JUDGE VASCURA

Defendant

COMPLAINT

Theabove named plaintiffmakes the following representations tothis court for the purpose

of obtaining judicial review of a decision of thedefendant adverse to tlicplaintiff.

1. The plaintiffis aresident of .Qjh^n 5" , OKf 0 . (City) (State)

PlaintifTs last four digits oftheir Social Security Account No. are gy /

2. The plaintiff complains of a decision whichadversely affectsthe plaintiffin whole

or in part. The decision has becomethe final decision of theSecretary for purposes

ofjudicialreview andbears the following caption:

IN THE CASE OF CLAIM FOR

m. b. H. SS j.

(Claimant)

Df Minor Child-onlyuse initials)

(Wage Earner) (Last Four Digits of Social Security No.)

3. The plaintiffhas exhaustedadministrative remedies in this matterand this court has

jurisdiction forjudicial review pursuant to 42 U.S.C. §405 (g).

Wherefore, plaintiffseeksjudicial review by this court and the ent^ofjudgment for such

reliefas may be proper, ineluding costs. fn. T>,

Date ^

Street Address ^ ,

fnarSA\^f?ld

Telephone Number

Case: 2:17-cv-00865-MHW-CMV Doc #: 8 Filed: 11/03/17 Page: 1 of 6 PAGEID #: 28
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Case: 2:17-cv-00865-MHW-CMV Doc #: 8 Filed: 11/03/17 Page: 2 of 6 PAGEID #: 29
Summaty Viewfitf

m/D. I-V

Pagel of4

Patient

Account Numben 306301

DOB: 11/23/2000 Age: 16 Y Sexs Male

Phone: 740-664-1028

Address: 9611 State Route 356, New Marshfleld, OH-45766

Pep: Health Centers Hopewell

m . D. H . Provider: Diana E Beko-Stretton, LPCC-S, NCC

Date: 08/02/2017

Subjective:

ChiefComplaints:

Medical History: Chronic constipation, Tremors.

Allergies: Sulfa: hives.

Objective:

Assessment:

Assessment:

1. Moderate episode of recurrent major depressive disorder - F33.1

2. Active auUstlc disorder - F84.0

3. Anxiety state, unspecified - F41.1

Plan:

Care Plan Details

Plan-ISP

ISPTvoe ISP review

Doesthe client have a co-oocuring disability or disorder? Yes

What Is/are the co-oocurlna disabllitvfs) or disoiderfs)? Other

Specify other co-occuring disorders Spedfic Learning disability

Besure to describe how the ISPaddressesissue(s) in an

Integrated manner, if treatment/referral Isoutside agency;

who and what.

Counselor will assist with

any material that needs

read.

Desired results In ctienfs words: notfeel sad and use coping

skills

Strengths Family supportive

AblllOes Creative

Preferences Counseling;PharmacoIoglc

Management Services

How will the above Strengths, Abilities and Preferencesbe

used to meet treatment goals?

Client guardian will bilng

him to counseling sessions.

Skills/Knowledge needed: Increased Insight and

Judgment

Natural/Community suoports needed: Guardians

ParenVGuardian/Communlty/other will: Not clinically Indicated

Therapeutic Interventlon(s) used service descriptionand

Responsible: Type of Provider

Counseling Individual and

Group by Therapist;CPST

IndMdual and Group by

QMHS, Trained Other or

Theraplst;PharmacologIc

Management by MD, DO,

APRN;Nurse Pharmacologlc

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Page2 of 4

V V' •

iManaaement bv RN. LPN

Therapeutic Inten/ention forIndividual and Group Counseling

Behavior therapy. Person

centered therapy, CBT,

Reality Therapy

FrBguencv of Individual and Group Counseling 1-4 X per month

Therapeutic Intervention forIndividual and Group CPST

[Assessment ofneeds, [Monitoring, Eliminating [Barriers, [Coordinating/Unlcages,

Crisis Management,

Advocacy,

Education/Training,

Empowerment/Skills

Building

Freouencv ofIndividual and Group CPST PRN

Therapeutic Intervention of Pharmacologic Management:

Frequency PRN

[Assess, prescribe and

[monitor psychotropic [medication and psychiatric

symptoms

Therapeutic Intervention of Nurse Pharmacologic

Management: Frequency PRN

Assist psychiatric providers

[as directed In monitoring psychotropic medication

and psychiatric symptoms

[and treatment, med.

Education

Therapeutic Intervention for Respite; Frequency PRN

Provide a safe, supervteed

[residoitial environment

during crisis; assess

[needs; provide with

[support, assist with

problem solving, planning

and crisis resolution

Goal #1 kes

Goal #1 In collaboration with client [Thinking

Linked treatment recommendation from: (for Initial plan only)IDAS update

Date of DAS update [08/02/2017

Start date 08/02/2017

Target Completion date 08/02/2018

Objective #1

[increase stop-and-think [behaviors to improve good [choices and reduce

[negative behaviors daily to

[lessthan once aweek per

parental and dient reports

[for athree month period.

Start date 08/02/2017

Duration 1 year

aientwlil:

Improve coping skills to

reduce negative behaviors

[to once a week orless per

parental and cflent reports

[for three months

AoD only youth level of care [Not applicable

Other agencies involved [School

School - Name, Contact and Title, Services Provided

[Alexanderschool, various

contacts, academic

[interventions

jQient meets the criteria of

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Summ^Viewforj

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Treatment recommendations/assessed needs:

counselingilndlvldual

counsellng;PharmacoIogic

Management

Rirther evaluations needed: None Indicated

Level of care/bidlcated servtres recommendation (youth AoD

only) None

Cllent/guardfan/fomUy response to recommendations: In agreement

Change In ISP required? Yes (complete the ISP to

record needed changes)

PrevWer; Diana E Bete-Stretton, LPCC-S, NCC

PatlenUOMHPVHlBiHMHHHIIV Date: 08/02/2017

ni

EteetronteaOystgned by Diana Beko-Stretton. LPCC5 NCC on <t»02/2017 at OZtOS PM BDT

Signoffstatus:Pending

Case: 2:17-cv-00865-MHW-CMV Doc #: 8 Filed: 11/03/17 Page: 5 of 6 PAGEID #: 32
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Case: 2:17-cv-00865-MHW-CMV Doc #: 8 Filed: 11/03/17 Page: 6 of 6 PAGEID #: 33