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Running head: ASSESSING CLIENTS1 Assessing Clients Kayla C. Sharpe Walden University
ASSESSING CLIENTS 2Assessing Clients Part 1: Comprehensive Family Assessment Demographic information: G.M., 31 year-old caucasian female Presenting problem: “Depression, insomnia, and poor focus and attention” History or present illness: G.M. presents with “worsening depression, trouble sleeping, and poor focus”. In the last 6 months she has been struggling with daily depressed mood, very low energy and motivation, and is having a hard time completing tasks of daily living. She reports frequent worry and has difficulty controlling this worry. She also reports daily episodes of irritability and trouble focusing, particularly while at work, which has impacted her performance. G.M. states that she is no longer doing things that she previously enjoyed, such as cooking. She reports getting approximately 3-4 hours of sleep a night, and has had trouble sleeping since she was 13. Her appetite fluctuates with her depressive symptoms. She denies suicidal ideation at this time, although she has had attempts in the past. She also denies homicidal ideation and auditory/visual hallucinations. Past psychiatric history: G.M. has been in therapy intermittently since the age of 13 when she found her mom after a suicide attempt. She called the paramedics and witnessed her mom being resuscitated and receiving a tracheostomy. As her mom recovered, she blamed her for not just “letting her die”. She has a history of a suicide attempt by overdose and one inpatient hospitalization in January 2019. Medical history: Chronic headaches, Temporomandibular joint dysfunction (TMJ), back pain, Irritable Bowel Syndrome (IBS), irregular menstrual cycle, miscarriage in 2018, cholesctomy, and rhinoplasty.
ASSESSING CLIENTS 3Substance use history: Denies caffeine, nicotine, alcohol, or recreational drug use. No history of substance abuse or dependence. Developmental history: No outstanding developmental history. Met all milestones as a child. Family psychiatric history: Mother- histrionic, borderline personality disorder, history of 27 suicide attempts. Maternal grandfather- suicide completition. Father- depression. Psychosocial history: G.M. currently lives with her husband in Denver, Colorado. She has her bachelor's degree, and currently works as a recruiter. She does not have any children. History of abuse/trauma: Reports extensive emotional and physical abuse from her mother throughout childhood. While in 5th grade her mom was abusing drugs, did not put out a joint, and set the house on fire and it was destroyed. In 6th grade she found her mother after an overdose and had to witness the paramedics resuscitate her. Review of systems General: A&Ox4. Appropriately groomed and dressed. Denies weight loss, fever, chills, weakness, or fatigue.