Name of Client ____Julia____________________________________________ Date___8/23/13__________________
__Well groomed __Neat _x_Casual __Unkempt __Unclean __Inappropriate __Bizarre __Unusual
__Cooperative __Guarded __Distractible _x_Agitated
__Clear __Tone (loud/soft) __Rhythmic __Poverty of Speech __Rapid _x_Slow __Stutter __Pressured __Slurred
_x_Appropriate __Blunted __Melancholy __Restricted __Labile __Inappropriate __Flat
__Even _x_Depressed/sad _x_Anxious _x_Irritable _x_Angry __Elevated __Euphoric/elated __Expansive __Passive __Pessimistic __Blunted
__Time __Place _x_Person
__High _x_Average __Low __Retarded
__Rational _x_Impaired __Immature __Impulsive
__Emotional __Intellectual __Denial __Blames Others _x_Blames Self __Slight Awareness _x_ Acknowledges problem
_x_Logical/Reality Based __Delusions __Obsessions __Tangential __Illogical __Loose Associations __Hallucinations __Ideas of reference/influence __Compulsions __Flight of Ideas __Circumstantial __Inhibited __Concrete __Abstract
Comments: Julia is depressed, anxious, irritable and angry. She is not upset with the staff here. She is upset at herself.
RISK STATUS CHECK
Violence/Abuse: (Domestic and Workplace, Child and Sexual)
Present Risk: ____None ____Low _x___Moderate ____High
Current: She and parents have been physically abusive recently to each other. Also the father of her child which is her current sexual partner has emotionally and physically abused her.
Past: The father of her child
Suicide/Homicide: (Past attempts, Prior inpatient admissions, Ideation, Intent, Attempt, Plan, Compromised ADL’s)
Present Risk: ____None ____Low __x__Moderate ____High
Current: With her past attempts and her depression right now she does has suicidal ideations.
Past: Two past suicide attempts and was hospitalized. She is very depressed, and gets very angry.
Other risks: (eating disorder, history of multiple diagnoses, non-compliance with earlier treatment, runaway): She is not eating.
Symptoms: Weight gain/loss Sleep decreased/increased Concentration increased/diminished Interest level decreased Fear
Restlessness Increased arousal Racing thoughts Irritability Avoidance Hopelessness
She is irritable, hopeless, eating problem- does not eat, restless, and avoids crowds. Also her interest level is decreased and she fears not being able to work or go to school because she was around drugs / alcohol too long and does not feel that she would be able to talk to people “straight”.
Strengths identified by client: She identified that she has a drug/alcohol problem and needs help.
Additional client strengths seen by clinician: I see that Jill is intelligent, and can go back to school and would excel if she gets this treatment that she needs. She knows that she has a drug and alcohol problem and needs to get help for that. Family members/others who will be supportive of client in treatment: mother and father
Family member/support people to have involved in treatment: mother and father.
CLINICAL ASSESSMENT/DIAGNOSTIC SUMMARY
(Evaluate, integrate and summarize the following information: Background, medical, social, presenting problem, signs & symptoms and impairments. Tie these in with the patient’s strengths and needs. Integration of data is more important than specific details.)
Jill came in presenting drug/alcohol abuse, depression, emotional / physical abused.
She was on the following medications that are not helping her at all. imipramine (Tofranil), lithium (Lithonate), and diazepam (Valium).
She has recently been abused physically by her parents. She was emotionally and physically abused by her sextual