25 February 2013
I. Presenting issues
Client C was recommended by her physician to see a therapist. Client C complains of difficulty falling and staying asleep, lack of interest in daily activities, and excessive crying. Client reports of feeling stressed about her current situation. Client describes that job is very stressful and she does not get along with her supervisor. Client said that her second daughter has an on-going legal case wherein she was accused of murder. Client explains that she gets irritated easily because she feels overwhelmed. Client is now separated from husband whom she suffered physical and emotional abuse. II. Background information
Client C is a 36-year-old divorced Hispanic female. Client is currently living in an apartment with her mother, sister, and two children. Client is working as an office assistant in a day care facility. Client completed some college and took Medical Office assistant program. Client states that she wants to go back to school someday and finish her degree. Client believes in God but does not have any religious affiliation. Client’s support system are friends from work. III. Family and individual history
Client C was born and raised in Chicago, Illinois. Client’s parents were never married but lived together until father passed away. Client is the 4th child among 6 children. Client has an older brother who is 44 years old, older twin brother and sister who are 42 years old, a younger sister who is 35 years old and a younger brother who is 34 years old. Client’s father passed away when she was 19 years old due to heart attack.
Client C describes her relationship with mother as “rocky” at the beginning but they are getting along fine now. Client reports that her father was very supportive of her. Client describes her relationship with her siblings as distant because she wanted to keep it that way. Client said that she keeps her distance with her siblings because they are very judgmental on everything she does.
At age 9, client was sexually abused by her father’s brother and by other tenants at their apartment. Client told her mother about the abuse but did she not believe her. During this time, client started distancing herself and not trusting anyone including her family.
Client‘s father was physically abusive towards her mother. However, client denied that her father physically abused her and her siblings. Client’s youngest brother was admitted in an inpatient hospital for homicidal ideation towards their mother.
Client has been influenced by family to use and abuse substances. All of client’s family members except mother used cocaine and alcohol. Client reports that she decreased her alcohol consumption and drinks beer every two weeks. Client used to drink 6-12 cans of beer and use cocaine daily. Client has stopped using cocaine for the past 5 months.
Client C is divorced from husband and is now in a relationship with M. Client C had four children with ex-husband. Client’s children are N who is 20 years old, E who is 17 years old, D who is 13 years old, and J who is 7 years old. Client’s son N moved out of their apartment and moved in with his girlfriend and stepchild. Client’s daughter E is currently incarcerated at Kankakee Correctional Facility. Client has close relationship with son N and gets to see him often. Client visits her daughter once a week and states that their relationship is typical of mother-daughter relationship. When asked by this writer what she means by typical, client said, “we always bump heads, we don’t agree.” Client considers her youngest daughter J as a mini version of herself. Client explains that, “I see a great deal of myself in my daughter.”
Client C has been seeing M for 2 months. Client has been struggling with the relationship because she is afraid that she will experience the same fate from her previous husband. Client does not know if she can trust M. Client states that