Wendy Lewis 3

Name: ______________________________ Date: _________________ DOB: _____1979_____

Age: _____________42________________ Start Time: _____2.00____ End Time: __3.30____

Identifying Information:

The client was referred to the facility by a social worker. The client sought psychological support for their PTSD. The client was a volunteer medical assistant at a military medical camp.

Presenting Problem:

The client experiences flashbacks of an accident rescue situation where the client was exposed to during his volunteer period. The client also experiences severe migraines and has been addicted to ecstasy as a pain reliever. The client has also complained of mild back pains which are persistent.

Life Stressors:

The client is stressed about losing their job after the onset of the PTSD symptoms. The client is also experiencing financial constraints. The client also suffers divorce stress after his wife left him when he started using drugs and also for financial reasons. The client is also fighting an eviction battle in court with limited finance and mortgage burdens.

Substance Use: FORMCHECKBOX Yes FORMCHECKBOX No

The client is addicted to ecstasy. Client is alcoholic.

Addictions (i.e., gambling, pornography, video gaming):

Client is addicted to gambling seeking to regain financial stability. Client also has a stealing addiction to maintain his drug use.

Medical/Mental Health Hx/Hospitalizations:

The client has one hospitalization record after overdosing on ecstasy. The client also has had four back surgeries in the previous four years. The client has a recorded allergy to latex.

Abuse/Trauma:

The client suffers trauma as a result of the volunteer period after being exposed to terrifying accident scenes as an ambulance assistant. The client has also been on the battle field as a soldier before their back injury in a deployment that led to the back injury. The client was also maltreated in his uncle’s house as an orphan.

Social Relationships:

The client is divorced with two kids who now live with his ex-wife. The client is a total orphan with no siblings having been raised as a single kid. The client has lived with his uncle after the death of his parents and has also been to two children home centers.

Strengths:

The client is positive about treatment and is ready to receive help. The client is also responding well to medical treatment with an impressive recovery graph.

Legal History:

The client has served six months for driving under influence. He has also served community service for property destruction.

Educational History:

Client is a college graduate with a bachelor’s degree.

Family Information:

Client is divorced with two children. He is a single child and is totally orphaned.

Spiritual:

The client is a Christian.

Suicidal:

The client has been suicidal and has tried drug overdose. He was hospitalized after the overdose and admits to having suicidal thoughts but he has not attempted suicide after the first attempt.

Homicidal:

The client is not violent and has had no history of violence or felt homicidal.

Mental Status Exam (MSE):

The client suffers depression and he is in the denial stage constantly. The client seems to be body picking with several piercings and wounds on his body. The client seems anxious, shaking his legs and constantly fidgeting. The client is grieved after losing his kids, wife, job, and could also lose his house. The client also seems to have cognitive impairment with very low concentration levels. The client’s mental state is unsteady and suffers depression.

Clinical Justification (Provide clinical justification related to client symptomology along with a DSM and ICD diagnosis based on client assessment):

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Initial Diagnosis (DSM 5):

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Initial Treatment Goals:

Goal:

Objective:

Intervention:

Target Date:

Discharge Plan:

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Name: _____________________________________________ Date: __________________