Marital Status: Single______________________ Ethnicity: x Hispanic; □ Non-Hispanic
Race: □ Asian; □ Black/African American; □ White/Caucasian; □ Other: ________________
Employment Status: Part-time (waiter) Occupation: Part-time waiter
Intake Date: 2_/25_/_2015_ Start time: __7pm?___ End time: _______ Duration: ________
Counselor Name: ___Gladys_______ Counselor Signature: ____________________________
1. Referral Source and Purpose of the Interview/Intake
Referred by his primary care physician. Exhibiting symptoms of anxiety (not based on any biological condition). Displaying symptoms of anxiety not related to medical condition. We are assessing psychological symptoms.
2. Presenting Problem
“I’m at the end of my rope. I can’t stand to be around my older brother and I can’t trust anyone in my family. I’m feel like I’m going to have a breakdown.”
3. Symptoms Sweating, nervousness, headache, lack of concentration, insomnia.
Physical already conduced a CT scan; results did not indicate any medical difficulties.
Doctor prescribed a mild anti-anxiety medication (Xanax).
Severity of Symptoms: □ Mild; x Moderate; □ Severe
Frequency/duration/severity/cycling of symptoms: x Daily □Every Other Day □ Weekly □ Monthly □ Episodic
Experiencing symptoms for: □ <6 months; x >6 months, but < 1 year; □ >1 year
Brother moved back 8 months ago.
4. Impairment / Degree that Presenting Concerns Affects Activities
□ Occupational □ Legal □ Marital □ Social Relationships □ Affect
□ Cognitive □ Physical □ Emotional □ Financial
Social relationships: impaired relationship with his mother; inability to communicate with his brother. Potential for physical escalation (fight with brother).
Affect: Always in a bad mood; easily frustrated. Short fuse.
Cognitive: Inability to think clearly and organize thoughts.
Physical: Symptoms as described above.
5. Family of Origin, Family Status and Extended Family History □ Mental Illness □ Substance Abuse □ Legal Issues □ Physical Abuse □ Sexual Abuse □ Divorce □ Other
Legal Issues: Extended family (two cousins) recently underwent an inheritance dispute when their parents passed away.
6. Childhood/Adolescent History □ Development □ Behavioral □ Elementary □ Middle School □ High School □ College □ Social Relationships □ Extracurricular Activity □ Substance Abuse □ Sexual Abuse □ Emotional Abuse □ Physical Abuse
Social relationship with brother: very distant as adults. As younger kids (Middle school and high school), his brother used to bully him. Sometimes that involved hitting (no major wounds, but still had significant emotional impact).
Jacob was a loner through high school; his brother always preferred to hang out with friends his own age (brother is 2 years older). Jacob felt rejected as a result.
7. Physical Health: □ Date of last physical exam: __10/2014______; □ Good physical health; or □ Medical problems: □ In the past □ Currently experiencing Concerns with: □ Sleep patterns; □ Appetite levels or changes; □ Exercise patterns
Sleep patterns: mild insomnia; sometimes was up in the middle of the night.
8. Current Medications:
Xanax for anxiety (mild dosage).
High School graduate; lives at home. Part-time job as a waiter at a local restaurant. Depends on his parents for financial support.