Psychology DAP

Client Name_Anessa Chart # _XXXXXX

Evaluating Counselor Shannen Carambia Date _4-17-2020

Please indicate “NA” if the question/section is not applicable to the client’s history. DO NOT LEAVE ANY SECTION/LINE BLANK.

Presenting Problem: (Include the client’s own words about why the services are needed, any referrals, and major stressors over the past six months.) Comment by Edwards, Brenda: Where are client’s own words included?

Anessa hurt her knee during a dancing competition. She was in her senior year when the incident occurred. The pain prolonged through the first several months of college. After having medication from various doctors, it is noted that she misused the prescribed drugs which started affecting her psychological well-being. The mother noted and raised the concern and recommended that she see someone. Some of the reasons as to why Anessa’s mother was concerned are that Anessa was taking up to 15 pills in a day which is drug abuse. Other symptoms are sleeping late, withdrawal from the family, reduced appetite, and distracted from school. Missing information about other symptoms which should be behavioral, cognitive, emotional, and physiological. What is your analysis of the life span for the client for appropriate sexual development? See assignment guidelines and rubric. Comment by Edwards, Brenda: The case study stated there would be a projected recovery time into college not that she was in college. Review the case again. Comment by Edwards, Brenda: In what way? This has to be specific to the problems

Past Treatment History: (Include past treatment history for substance abuse AND mental health services.) Anessa did not disclose past treatment for substance abuse or mental health services???

The first treatment Anessa was Vicodin as pain reliever. The prescription was supposed to last for a month as they were 60 pills. She was supposed to take a max of two pills in a day. Her prescription was refilled again after one month with 60 pills. The medications ended within the first three weeks as she started overdosing. The first week of the second month of prescription she took 2×1. The second week she started taking 3×1 and the third week she moved to 4×1. Comment by Edwards, Brenda: This was medical treatment for her injury not substance abuse???? Comment by Edwards, Brenda: Did she overdose or take more than prescribed?

After the medication ended she was prescribed with 30 OxyContin pills to last a month. The medications ended early and moved to another doctor who prescribed hydrocodone to last for a month. However, she had visited two different doctors and had collected medications to sustain her for six months. However, she consumed all the prescription within a month.

How are you addressing past mental health services?

Family History: (Include biological family members, number of children, divorce, separations; describe what it was like growing up in this family, and include substance abuse and psychiatric history of family members.)

Anessa was brought up in a stable and supportive family. The family supported her to pursue her dreams even from a young age where the sfhe embraced dancing and received many awards. Her father was an African American and her mom was Hispanic. Her dad possessed his limousine commercial while the mother was a house wife and focused on taking care of the children. Anessa was a third born among five children and all the kids were maintained and stimulated to pursue their talents. Was there substance abuse and psychiatric history of family members? Comment by Edwards, Brenda: What does stable mean? Make this specific to her family composition and social status Comment by Edwards, Brenda: ????

Biological history? Illnesses, surgeries, medications

Substance Abuse Drug History: (Include top three drugs of choice.)

1. N/A- there has to be drug used. Pain relievers are opiates

List any withdrawal symptoms as reported by client (sweats, constipation, DTs, seizures, etc.):

N/A

Social History

Client’s Current Life Situation: (Summarize present living arrangements and any current social supports.)

The client lives with the family under the care of her father and mother. There are other four siblings as she is a third born in a family of five. However, there are no other social supports noted.

Sexual Orientation:

N/A

Spiritual Beliefs:

N/A

Employment History

Employment: (Include longest continuous employment, type of employment, typical length of stay, present employment, and military history.)

N/A

Education: (Note highest level of schooling completed, school performance, peer relationships, and learning problems.)

Anessa is a college student as the illness kicked off during the early month on college. She is a student of Juiliard College. She is still in high school. The recovery was projected to last into college review this information for clarity Comment by Edwards, Brenda: ????

Medical Health History: (Include illnesses, surgeries, medications [OTC and prescription]. Note any current medical problems, physical disabilities, and/or eating disorders. Include gynecological history and pregnancies.

The only medical history is the knee injury and the medications given include Vicodin, OxyContin and hydrocodone.

Primary Care Physician:

Name: _______________N/A__________________________________________

Address: _______________________________________________________

Phone: ______________________________ Fax: _______________________

Date of Last Physical Exam: ____________________________________

Hospital of Choice: ___________________________________________

Allergies: ______________________________________________________

Medical Medications: (Include name of medication, dose, condition it is treating, and its effectiveness.)

N/A

Mental Health/Psychiatric History:

Have you ever been treated for a psychiatric illness: Yes or No

N/A

Please explain: (Include if client has been hospitalized, seen by a mental health professional, what they were seen for, and how long they were seen.)

Any SI/HI or plan in past or present? (Please explain if “yes”) this should not be skipped

Psychiatric Medication History:

Legal History: (Note any charges and dates, any outstanding warrants, court dates, description of crimes, convictions, incarcerations, etc.)

· No legal issues

· Currently on probation

· Pending warrants

· Jail term served

· Court cases pending

· Parole

Explain with detail any and all of the above checked:

N/A

Clients Self-Assessment of Strengths:

1. N/A Comment by Edwards, Brenda: Review the case and consider her resilience, education, family support

2. ______________________________

3. ______________________________

Clients Self-Assessment of Weaknesses

1. N/A Comment by Edwards, Brenda: Reconsider the case and consider impulsiveness with taking drugs, not asking for help, not using her tenacity and strength to avoid abusing drug

2. ______________________________

3. ______________________________

4.

Recommendations: (This narrative section pulls all of the information together, with a clinical opinion about what the primary issues are and what should be done to address them. Also state potential referrals to rehabilitative, IOP, and so on that are appropriate at this time.)

To eradicate the abuse of drugs the source of the problem needs to be identified. By treating the knee the drug abuse will be eradicated. However she has to be engaged through prescription drug monitoring program. The monitoring program will ensure that the medications are taken as prescribed.

Clinician/Counselor Signature: Shannen Carambia Date: 4-17-2020

Clinical Director Signature: _______________________________________ Date: _