You only need to clean up and make my sentences and phrases nice. If its already in a bullet point, leave it there. No need to change any formatting.

Client Full Name: LECM

Date of Birth:

Place of Birth:

Date of Evaluation: Evaluator’s Qualifications: Grace Pacheco, M.A., MFT is a bilingual licensed Marriage and Family Therapist (MFT) who specializes in the assessment and psychological treatment of individuals who have been victims of violent crime or other severely traumatic experiences. She earned a master’s degree in counseling psychology from The Wright Institute, and a bachelor’s degree in psychology and Spanish language from the University of San Francisco (USF). She holds a license to practice psychotherapy in good standing with The California Board of Behavioral Sciences, and legally and ethically practices in accordance with the California Business and Professions Code and The California Association of Marriage and Family Therapist's (CAMFT) code of ethics. In the state of California, Marriage and Family Therapists (MFT’s) are trained and authorized by law to assess, evaluate, diagnose, and treat a broad range of severe and chronic mental disorders— as well as determine how such psychological disorders are affected by culture, oppression, poverty, stigma, and other social stresses. Ms. Pacheco regularly conducts mental health assessments, performs psychological testing, engages in professional psychological writing, contributes to university and college level courses as a guest lecturer, and provides expert testimony in court settings within her scope of practice and competence, as established by her formal graduate education, advanced training, and clinical experience. Purpose of Psychological Assessment This report serves to provide a professional clinical opinion regarding NAME, who is petitioning for a U Visa based on being the victim of a CRIME in CITY, California on DATE OF CRIME. The assessment was conducted in person, in Spanish language, at a private psychotherapy office in Pinole, California on DATE. Included in this report are the clinician’s assessment, evaluation, and proposed treatment for the applicable clinical diagnoses. The subject of this evaluation has authorized the evaluating clinician to release confidential information relevant to her psychological symptoms and clinical diagnosis for the purposes of her petition.

She experienced a somatic response after the crime, seen in the aftermath of severely being traumatize in which she was Vomitting phlegm following crime, shaking and trembling. She stated that when the police requested that she identity the criminal (after locating him) she explained that they transported her and that she was so afraid that she wanted to throw herself out of police car on the way to identify the person that they caught. She indicated that she coped with her horror by Prayed to God that nothing bad will happen to her and the police are trustworthy.

Testified at court trial, Got home and cried, felt tterrified, Couldn’t look at him in the face in the court room, the criminals family was present at the hearing and the client felt terrified that they would seek revenge on her, especially if they ever learned she has a child. She felt worried about retaliation. Significant Functional Changes Provoked by the Crime

A. New Psychological Symptoms

NAME explained that following the violent crime that occurred, she noticed new psychological symptoms that began to emerge shortly afterward. She endorsed experiencing repetitive, intrusive, and unwanted memories of the aforementioned traumatic experience, physiological arousal upon recollecting distressing memories, hypervigilance of surroundings accompanied by a startle response, avoidance of thoughts or discussions of the psychologically traumatic event, and avoidance of certain types of people (people that are similar in appearance to the assailant), situations (cars that come within close distance to her), or activities that cue flashbacks of the crime (returning to the area where the crime occurred). .

B1. Sleep Disturbances NAME reported that since the traumatizing experience, she has sustained disruptions in prior normal and restful sleep patterns. “My blood freezes when I hear anything” and I get up in the middle of the night now and check the doors, windows. She relocated and still feels the same. I used to sleep normally. I was told the first night by my husband that I was screaming in my sleep and he had to wake me up. I still have nightmares of someone coming in the trailer home and wakes up agitated and sweating. I breathe, drink water to calm myself down.

B2. Changes in Appetite NAME described having a normal and healthy appetite before the incident, and has since observed a drastic shift, correlated directly with her mental status. I lost weight a lot during the period of the court hearings (3 months). I went down an entire women’s dress size. I started buying size small after being medium. because I had no hunger

B3. Emergence of Somatic Symptoms

Somatic symptoms are physical manifestations of psychological symptoms commonly observed in victims of severely traumatic events. Apart from the vomiting of phlegm immediately following the crime, she has since developed chronic headaches, painful stomachaches (from holding tension in her abdomen) and dizziness that she did not have prior to the incident.

C. Daily Activities

NAME stated that after the crime, she experienced significant challenges in her ability to function in her role as a housewife, due to an impairment in concentration and focus, an overlapping psychological symptom of both PTSD. After the crime there was a long time I didn’t want my spouse to go to work or be alone at home. She felt afraid to be home I alone without him. He told me if anything happens to call him immediately. It was hard to return to the routine of taking care of the household responsibilities. I get paranoid that someone might be nearby and come for vengeance. She was slower at household chores, less efficient with her time, and struggled with concentration and focus (forgetting easily, distracted by racing thoughts about the crime, despite being indoors) NAME cited a loss of interest in pleasurable activities that she previously enjoyed prior to the incident— a hallmark symptom of Posttraumatic Stress Disorder (PTSD). Before the crime, she took her children to the park, she went walking to the city center, she would leisurely push the stroller and go out shopping. Since the crime happened, she , only goes out if her husband is with her and is on guard for something catastrophic to happen at any moment.

Following the crime, NAME admitted to developing new negative beliefs about the world, such as the assumption that the world is a completely dangerous place and that others are untrustworthy, prompting feelings of distance and isolation from other people. She stated that it affected the quality of her marital relationship because her husband simply doesn’t understand how terrifying it was (feels isolated and alone with her unique experience). Used to be more relaxed with my kids and now I am very focused on their safety I always tell my kids that they should stay inside and be careful, I started having talks about safety with my kids and avoiding strangers and its important to me. I was more socialable and now I want to stay at home.

E. Spirituality

NAME commented that she grew up in the Catholic faith in El Salvador, and after the crime happened, she observed a change in her personal relationship with God. Before the crime, she attended church services went every week. After the crime she felt distantfrom the church community because she felt afraid to leave the home and go out. After one year passed, she returned to going every week. Since the crime, she has started new prayer routines, praying for people who are bad, for kids that maybe didn’t eat, orphans. She emphasized that she used her faith in the moment of the crime at various times asked for protection, feels like God worked in her life through the officers who helped her, through the person who offered to translate for her on the street, and through the passersby who offered her a cup of water after she was attacked. all were sent form God..

F. Cultural Considerations

Clinical Diagnosis Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Principal Clinical Diagnoses

309.81 Posttraumatic Stress Disorder (PTSD)

Psychosocial Problems and Contextual Risk Factors V62.89 Victim of Crime V60.2 Low Income V62.4 Social exclusion or rejection

Reported Medical Conditions Hypotension Diagnostic Criteria and Administered Psychological Measures NAME qualifies for a diagnosis of Posttraumatic Stress Disorder (PTSD) based on meeting minimum criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Diagnostic criteria for PTSD is highly specific and must include: exposure to actual or threatened death, serious injury, or sexual violence and at least one intrusion symptom (intrusive or recurrent distressing memories, dreams, dissociative reactions such as flashbacks), persistent avoidance of stimuli associated with the traumatic event(s), negative alterations in cognitions and mood (inability to remember an important aspect of the traumatic event(s), persistent and exaggerated negative beliefs about oneself, others, or the world, persistent distorted cognitions about the cause or consequences of the traumatic event(s), persistent negative emotional state [e.g. fear, horror, anger, guilt, or shame]), markedly diminished interest or participation in significant activities, detachment or estrangement from others, persistent inability to experience positive emotions, and marked alteration in arousal and reactivity (irritable behavior or angry outbursts with little or no provocation, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbances) (American Psychiatric Association, 2013). To validate the diagnosis, I administered the PTSD Checklist (PCL-5) for DSM-5, a standardized and validated measure published by the U.S. Department of Veteran’s Affairs National Center for PTSD, that assesses the 20 symptoms of Posttraumatic Stress Disorder (PTSD) in civilians. NAME obtained a clinically significant score, warranting a provisional diagnosis of Posttraumatic Stress Disorder (PTSD). Suicide Risk Assessment I assessed NAME for current suicidal ideation, plan, or intent, and at this current time, she does not warrant a need for an involuntary psychiatric hold.

Test for Malingered Mental Illness In order to validate the results of the aforementioned screening instruments and self-reported data, I also administered the Miller Forensic Assessment of Symptoms Test (M-FAST), a screening measure for the detection of feigned or malingered mental illness. The questions on the M-FAST are designed to screen for those persons who may seek to exaggerate mental health symptoms for a secondary gain. The M-FAST is standardized and validated. Scores of 6 or greater are considered to be highly suggestive of malingered psychopathology and may require additional screening. NAME scored a 0 on a scale of 0 to 25, suggesting a highly unlikely possibility of malingering or attempting to falsely report mental health symptoms. Clinical Impressions & Recommendations The evaluating clinician has determined and concluded that NAME is a victim of a psychologically traumatizing experience, and subsequently, is suffering from symptoms of Posttraumatic Stress Disorder (PTSD). It is believed that this individual could greatly benefit from professional mental health services to reduce her psychological symptoms. Formal evidence-based treatment options for the assigned diagnoses include psychiatric medication, psychotherapeutic treatment, or a combination of the two modalities for best results. It is also essential to note that such formal mental health services still remain highly stigmatized within immigrant communities, and that natural remedies, spiritual practice, and traditional healing methods are often culturally preferred. It is recommended that he make an active decision to begin to reduce her psychological symptoms with the modality of her choice, so that she can get the support that would help her improve her level of daily functioning.

Signed,

Grace Pacheco, M.A., MFT Licensed Marriage and Family Therapist #90751

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Barona, A. & Santos de Barona, M. (2003). Chapter 4: Recommendations for the Treatment of Hispanic/Latino Populations. In Psychological Treatment of Ethnic Minority Populations. Retrieved from https://www.apa.org/pi/oema/resources/brochures/treatment-minority.pdf

1