Doretha A Duncan
Houston Graduate School Of Theology
Rev. Jerry L. Terrill, DMin., LPC-S,LMFT-S
November 19, 2014
Client Name: Peterson, Stacey
Date of Birth: 02/07/92 Age: 22
Examiner: D.A. Duncan
Date of Evaluation: 11/19/2014
Reason for Referral: Crack Addiction
Behavioral Observations: Ms. Peterson is a 22 year old, African-American woman, self-referred for inpatient treatment due to Crack and alcohol abuse. She is currently unemployed, homeless, and has charges pending due to a number of "bounced" checks written over the past several months. She was of average height, thin, and her brown hair in locks. She was dressed in baggy blue jeans, a white t-shirt and tennis shoes. Stacy is very insightful, talkative, with rapid eye movement, but appears hopeful. She exhibited polite mannerisms and her posture was good.
Presenting Problem: Ms. Peterson is a 22 year-old, bisexual, African-American female. She has been using Crack cocaine and alcohol for the past eight years. She uses 3-5 times daily.
Background Information: Stacey reports that her father was an alcoholic and her mother experienced physical and emotional abuse throughout her childhood. Her father died of liver disease at the age of 75. Stacey also reports that at the age of 17, she was kicked out of her family's home because her parents suspected that she was lesbian. Although they live in the same town, she has not had any contact with either parent for 7 years. Stacey describes her relationship with his older sisters as "fair." Stacey is not presently involved in a steady relationship, but does have a network of friends in the local lesbian/gay community with whom she has been staying off and on. At the time that she left home, Stacey survived by becoming involved in sexual relationships with older men and women, many of whom were also abusive. She has had numerous sexual partners (both male and female) over the past 7 years, has traded sex for drugs and money, has had sex under the influence of drugs and alcohol, and has been made to have sex against her will. Stacy reports she had been raped 3 times while under the influence. Stacey identifies herself as bisexual, not lesbian. Stacey first used alcohol at age 14, when she had his first sexual encounter with a female. She began using other drugs, including marijuana by age 18 and amphetamines and cocaine by age 21. At 22, after various failed relationships, she began using crack.
Axis I: 302.85 Sexual & Gender Disorders , V61.20 Parent-Child Relational Problem Alcohol Use Disorder 305.00 – Alcohol Abuse F10.10, 303.90 – Alcohol Dependency, Cocaine Use Disorder 306.00 – Cocaine Abuse F10.10 305.60 – Cocaine Abuse F14.20
Axis II: None, Axis III: None
Axis IV: Problems with primary support group
Axis V: 70
Recommendations: Use list format here too, e.g.
1) Individual Psychotherapy. Ms. Peterson would benefit from individual therapy interventions to further assess her experience of depression, assist her developing social skills, and address her struggle with addiction progress.
2) Group Therapy. Ms. Peterson may benefit from participating in various support groups as well as psycho educational group therapy to help develop her social skills and address her anger due to the abuse of being raped. Ms. Peterson would also greatly benefit from groups to aid in the approval and validation from others process.
D.A. Duncan, M.A., Houston Graduate School Student
Ms. Peterson was on time and her dress was dingy and unorganized, but clothes fit her body. Ms. Peterson appeared to have a healthy appearance with dry skin and red eyes. Ms. Peterson shared with me her desire to get clean and organized and perhaps enroll in some form of higher education, but states she is