PSY 614
Bullock
p. 1 of 3
Community Counseling and Assessment Clinic
Sample Initial Assessment Report #1
Client: / Jane Doe / Interviewer: / Ima Counselor, B.A.Assessment Date: / July 1, 2009 / Supervisor: / Emily Bullock Yowell, Ph.D.
LETHALITY SPECIFICATION:
Ms. Doe reported that she is not presently experiencing suicidal or homicidal ideation. She stated that she has experienced mild forms of both in the remote past but has never attempted to harm herself or anyone else.
PRESENTING PROBLEM AND HISTORY:
Ms. Doe is a 23-year-old Caucasian female who reported that she is currently a Psychology major at the University of Southern Mississippi in Hattiesburg, MS where she has a cumulative GPA as 2.86. She described her future career plans as “undecided” although she plans to graduate in December of 2010. She stated that she currently lives in Hattiesburg with her boyfriend and is employed part-time at a local restaurant chain. Ms. Doe listed her gross annual income as $14,000, adding that she has a difficult time living on this amount.
Ms. Doe arrived on time to the interview and completed all requested paperwork without difficulty or omission. She presented as a tall and slender Caucasian female who appeared somewhat younger than her stated age of 23. She was well-groomed and dressed appropriately for a college student in this setting. She was alert and fully oriented throughout the interview. Overall, her attitude toward the interviewer was agreeable and compliant, as evidenced by answering each question posed. Although she described her mood as depressed, she smiled and laughed when discussing humorous experiences.
Ms. Doe stated that she was interested in obtaining counseling in exchange for class credit in PSY 312. Initially, she had a difficult time articulating any presenting concerns other than general dissatisfaction with her academic performance. She said that she usually feels like she knows the material prior to an examination but continues to perform poorly.She stated that she has never been tested for learning disabilities and wonders whether she might have one. She said that she earned mostly “As and Bs” in high school and never experienced difficulty until college. Ms. Doe also reported being “worried” about her relationship with her boyfriend. Although they have been living together for the past two months, she stated that he has been talking about “wanting to leave” lately. She reported that the prospect of him leaving is particularly difficult for her because “he's my best friend...really my only friend.” She said that she has felt “sad,” has noticed herself crying more often, and has had less energy than normal for the past two weeks after her boyfriend told her that he is unhappy with their relationship.
Ms. Doe reported that she is currently sleeping approximately six hours a night. She said that she is often awakened by her boyfriend watching television or talking on the phone, finds it difficult to resume sleep, and often feels tired after waking in the morning. Although she initially described herself as having a poor appetite, she later said that she consistently eats three complete meals a day and has not lost any weight.
Although she initially described her boyfriend as her only friend, Ms. Doe was able to identify other sources of social support. She stated that she often copes with her sadness by “thinking about things myself,” but added that she also has some friends to whom she can talk about her feelings. Yet, Ms. Doe reported that she is not as interested in socializing as she once was and finds that she is less interested in most things lately.
Ms. Doe reported that she does not have any medical problems other than some pain from an old high school cheerleading injury. She reported sometimes taking her mom’s or friend’s pain pills when the injury “acts up.” She stated that she does not currently use alcohol or illicit drugs. She reported currently taking birth control pills.Ms. Doe stated that she said that she has never received counseling, been hospitalized for emotional problems, or taken psychiatric medication. She reported that she has never had any unwanted sexual experiences and that she was not the victim of childhood physical or sexual abuse.
The OQ-45.2 and MINI International Neuropsychiatric Interviewwere administered at the time of this interview. Ms. Doe’s total score on the OQ-45.2 exceeded the clinical cutoff, indicating that she reported clinically meaningful distress on this instrument compared to typical college undergraduates. With regards to the Symptom Distress subscale, she scored in the 98th percentile as compared to typical college undergraduates by indicating that she frequently feels “weak” and “blue” and sometimes has “difficulty concentrating.”Ms. Doe endorsed only one critical item, stating that she “rarely” feels angry enough at school/work to do something she might regret. When asked about this item in the interview, she reported that she was referring to wanting to quit school at times when she feels too sick or sad too attend. Ms. Doe endorsed thefollowing screening module of the MINI: Major Depressive Episode, Social Phobia, and Substance Abuse. After administering the modules, she only met criteria for Major Depressive Disorder. She indicated during the interview that she cries most days, has difficulty concentrating on academic tasks, and has lost interest in nearly all social activities.
CLINICAL IMPRESSIONS:
Although Ms. Doe initially described interest in class credit and academic concerns, it appears that her primary reason for seeking treatment involves her relationship with her boyfriend and related depressive feelings. She appears to be experiencing sufficient distress to motivate her for counseling and is reporting significant depressive symptoms in response to hearing her boyfriend say that he was thinking of ending their relationship. The nature of her reaction to the potential loss of this relationship does not appear inappropriate. Yet, it is significantly affecting her ability to function satisfactorily at work and at school. Thus, her presentation is consistent with Major Depressive Disorder, Mild. During the interview, Ms. Doe was pleasant to be in the room with and seemed open to expressing her concerns. Yet, she often answered questions with a yes or no adding little explanation. She seems to be adequately motivated for treatment and has formed some appropriate ideas for treatment goals.
Tentative DSM-IV DiagnosesAxis I: / 296.21 Major Depressive Disorder, Mild
Axis II: / 799.9 Diagnosis Deferred
Axis III: / Chronic pain (by client report)
Axis IV: / Relationship problems, academic difficulties
Axis V: / GAF = 80 (Current)
TREATMENT RECOMMENDATIONS:
It is suggested that Ms. Doe would benefit from counseling in which she is encouraged to express her feelings around the potential loss of her romantic relationship, have her experience of sadness normalized, and learn coping skills. Ongoing assessment of her depressive symptoms is suggested to assure client safety. The counselor may also want to consider strategies for enhancing Ms. Doe’s social support. Finally, if Ms. Doe’s concerns about academic difficulties continue, it may be worthwhile to recommend that she seek a learning disabilities assessment.
NOTES TO ASSIGNED THERAPIST (If needed):
Ms. Doe reported that the assigned counselor may contact her at home and may leave a message on her answering machine. Due to her work and class schedule, she anticipates scheduling to be difficult.
Recommended Practicum Assignment:
Practicum I / XPracticum II
Practicum III
Practicum IV
I would be interested in working with this client:
YESSignature of InterviewerDate
Signature of SupervisorDate