assignment use the questions below to complete the paper and case study attached please use it!!!
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sabrinacasestudy.pdf
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COU 680 Adult Psychosocial Assessment Sabrina
Date of appointment: Today Time of appointment: 5:00 pm
Client Name: Sabrina Hinajosa Age: 29 DOB: 3/23/89
Gender: Male Female Transgender Preferred Name/Nickname: N/A
Ethnicity: Hispanic Non‐Hispanic Race: Caucasian
Current Marital/Relationship Status: Single Married Divorced Widowed Domestic Partnership
Name of Person completing form: Sabrina Relationship to client: Self
PRESENTING PROBLEM (Briefly describe the issues/problems which led to your decision to seek therapy services): I recently lost my mother-in-law to a sudden heart attack immediately prior to the recent hurricane. Within a matter
of a single day I lost the mother figure in my life, was evacuated from my home, and had a hurricane destroy parts
of my house. I’m completely overwhelmed, sad, and angry at the world.
How severe, on a scale of 1‐10 (with 1 being the most severe), do you rate your presenting problems?
MOST SEVERE 1 2 3 4 5 6 7 8 9 10 LEAST SEVERE
PRESENTING PROBLEM CATEGORIZATION: (Please check all the apply and circle the description of symptom)
Symptoms causing concern, distress or impairment:
Change in sleep patterns (please circle): sleeping more sleeping less difficulty falling asleep
difficulty staying asleep difficulty waking up difficulty staying awake
Concentration: Decreased concentration Increased or excessive concentration
Change in appetite: Increased appetite Decreased appetite
Increased Anxiety (describe): I have a lot of fear of the unknown. Everything feels out of my control.
Mood Swings (describe): I’m irritable all of the time. I go back and forth between extreme bouts of sadness and complete anger and rage at the situation. The only place I feel calm is with my kids
and only because I really focus on making sure they are ok.
Behavioral Problems/Changes (describe): I struggle to stay focused on anything other than taking care of my kids. I feel aimless and purposeless and have stopped putting forth much effort at work or in our home.
Everything just seems both overwhelming and pointless.
Victimization (please circle): Physical abuse Sexual abuse Elder abuse Adult molested as child
Robbery victim Assault victim Dating violence Domestic Violence
Human trafficking DUI/DWI crash Survivors of homicide victims
Other:
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Other (Please describe other concerns):
How long has this problem been causing you distress? (please circle)
One week One month 1 – 6 Months 6 Months – 1 Year Longer than one year
How do you rate your current level of coping on a scale of 1 – 10 (with 1 being unable to cope)?
UNABLE TO COPE 1 2 3 4 5 6 7 8 9 10 ABLE TO COPE
EMPLOYMENT:
Currently Employed? Yes No If employed, what is your occupation? Bank teller
Where are you working? XYZ Bank
How long? 3 Days/Months/Years
Do you enjoy your current job? Yes No What do you like/dislike about your job? I used to really like my job. I really like the people I work with and it offers a lot of good interaction with people in the nearby
community. I’m typically a really outgoing person that people like, so this has been a good fit for me. Right now
though, I don’t really get anything out of it other than knowing I need the job because we need the money. It’s
like I go in and do what I have to do until I leave. My focus has been lacking and it is showing.
If you are not currently employed, how long has it been since you last worked? Months/Years
What was your occupation before becoming unemployed?
What led to becoming un‐employed?
PSYCHIATRIC/PSYCHOLOGICAL HISTORY:
Are you currently being seen by a psychiatrist? Yes No
If yes, name of current psychiatrist Length of Treatment
Have you ever been diagnosed with a mental health, emotional or psychological condition? Yes No
If yes, what diagnosis were you given? Post-Traumatic Stress Disorder
When? 5 years ago
By Whom? Dr. Mental Health
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Previous counseling/hospitalizations for mental health/drug and alcohol concerns
Dates of Service
Place/Provider
Reason for treatment
Were the services helpful?
January 2013-August
2013
JKL Counseling and
Wellness Center
Rape Trauma Yes
SAFETY CONCERNS:
Are you presently suicidal? Yes No If Yes, please explain
Have you ever attempted to commit suicide? Yes No If yes, when and how? Well, I didn’t fully attempt. I had plans to jump off the bridge near my house, but ultimately changed my mind.
Is there a history of suicide in your immediate and/or extended family? Yes No My father committed suicide when I was 13 years old.
Are you presently homicidal? Yes No If Yes, please explain
Additional Information: (please add additional information as needed to address past and current safety issues): I’m not actively suicidal, but I am aware that my last experience got me really close. I don’t feel as out of control right now
as I did then, but I have some small fear that those feelings of chaos and rage are resurfacing and I won’t be able to
control them on my own.
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FAMILY MENTAL HEALTH HISTORY
Please identify if any members of your family have had a history of any of the following mental health/drug
abuse/legal concerns.
Family History
Depression
Anxiety
Bipolar Disorder
Schizophrenia
ADHD/ADD
Trauma History
Abusive Behavior
Alcohol Abuse
Drug Abuse
Incarceration
Self X X
Mother X X X X
Father X X X
Sister
Brother
Maternal Uncle
X X X X
Paternal Uncle
X
Maternal Aunt
X
Paternal Aunt
Maternal Grandmother
X X
Paternal Grandmother
Maternal Grandfather
X
Paternal Grandfather
X X
Biological Child
X
RELATIONSHIP/MARITAL STATUS
Current Marital/Relationship Status: Single Married Divorced Widowed
Live‐In Partner Significant Other (Not Living Together)
If applicable, list divorces and separations:
How do you identify yourself: Heterosexual Homosexual Bisexual Questioning
What do you think is important for us to know about your significant relationships – current & past? My parents divorced when I was about 3 years old and I lived largely with my mom although I saw my dad every couple of weeks.
My dad was always “fun” but really irresponsible. I remember that even as a kid. He got in trouble a lot and spent some
time in jail for stealing a car. He just didn’t seem to ever take responsibility for anything. His bipolar disorder only
complicated that experience. He went from the highest of highs to the lowest of lows and ultimately ended up shooting
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himself one night, alone in his apartment. My mom was a bit of a “hippie”. She came from a highly abusive and
controlling family, so she decided to take the opposite approach with me. She was, on occasion, physically abusive to
me, but mostly she just moved in and out of the world high on drugs and full of “free love”. I lived a nomadic existence
with her and I often felt like the parent to my parents. I met my husband Tony in high school. We started dating and I
immediately fell in love with him and his family. They welcomed me in for meals and made life feel “stable”. His
mom, Maria, was like the mom I always wanted, and she often said I was the daughter she wished she had. We were
very close, and I loved her very much. I have two daughters of my own (6 and 8), and they are the center of my
universe.
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FAMILY COMPOSITION
Spouse/Significant Other’s Name: Tony Hinajosa Age: 30
Living with client Not living with client
Employed Currently: Yes No If Yes, place of employment: BIG House Construction
Occupation: General Contractor
Please list the names, ages, relationships and other relevant information regarding all immediate family members
whether living in‐ or outside the home. Please include all members currently residing in YOUR household.
Name
Gender
Age
Relationship To Client
Living With Client
Tony Hinajosa Male 30 Spouse Yes
Lyla Hinajosa Female 8 Child Yes
Amelia Hinajosa Female 6 Child Yes
Henry Hinajosa Male 58 Father-in-law No
Meg Wick Female 56 Mother No
What else do you feel/believe would be helpful, or important for us to know/understand about your
relationships with your family or about your family members?
I don’t have regular contact with my mom. She lives about three hours away and we only really see each other around
Christmas and out of a sense of obligation—mostly for my kids. She doesn’t really put in any effort and I don’t either.
RECENT LOSSES:
Family Member Friend Health Lifestyle Job Income Housing None
Who? Mother-in-law When? 1-month ago Nature of Loss? Heart attack
Other Losses: father—suicide when I was 13; all my grandparents are also deceased
HOUSING:
Would you consider your housing to be: stable unstable
Do you currently:
Own Rent Live with relatives/friends (temporary) Emergency Shelter
Live with relatives/friends (permanent) Homeless Transitional Housing
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How long have you lived in your current living situation? 6 years
How often have you moved in the past two years? N/A
What else do you think is important for us to understand about your housing/living situation? We currently live at home but our house was flooded with the hurricane, so it needs pretty extensive repair.
Typically, we would stay with my in-laws, but with my mother-in-law’s death there have been a lot of family visiting,
and we don’t want to overburden Henry. I also don’t think I could handle being there without her. Just the thought of
that house makes me cry. Really any reminder of her does, but that is particularly hard for me. Our home is functional,
but we are without carpet and the paint is peeling off. My husband is in construction, so I know we will get it fixed
eventually, but it is chaotic and we don’t have the insurance money to pay for anything right now.
FOSTER CARE INVOLVEMENT
Have you ever been in foster care? Yes No From age to age
Reason: Familial Placement Non‐Familial Placement
HEALTH HISTORY
How would you describe your overall health? Generally good
Do you have any health issues? Yes No If Yes, please list below.
Do you have any recurrent medical conditions such as allergies or asthma? Yes No
If yes, please list:
Please list below current medical problems, physical limitations, sleep problems, unusual eating habits, poor hygiene,
overall physical fitness, head injuries, early childhood infections, eating disorders, knee or back injuries, asthma, etc.
Medical Conditions Are you currently
receiving treatment?
Provider
Does this condition cause stress or
impairment at this time?
What have you found that helps?
High blood pressure Yes Dr. Medicine Yes-I need to be more
consistent on my
medication which
stresses me out but the
stress I am under leads
me to forget
I just need to stay on my
medication as prescribed
Insomnia No Yes-I find it very hard
to go to sleep or stay
asleep
Nothing
Lack of appetite No Yes, but only because
I know I should be
Trying to eat when my
kids eat
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Do you currently take any medications? Yes No
Please list medications (including psychotropic, over‐the‐counter, herbal remedies) that you have taken in the
past 6 months.
Medication Dosage Frequency Prescribed By Reason for Medication
Diuril 500mg 2x/day Dr. Medicine High Blood Pressure
Are you taking the medications as prescribed? Yes No If No, please explain: I have trouble remembering to take it consistently. I usually remember at least one dose per day, but with all that is going on, I frequently forget.
Symptoms start fairly quickly and then I get angry at myself and this whole situation.
Additional information (if needed):
Have you ever had a serious accident/illness or hospitalization? Yes No
Please list all past hospitalizations, surgeries, accidents, or illnesses in the chart below.
Reason for Previous Hospitalizations, Accident, Illness
Date/Location of Hospitalization
Traumatic rape December 2012/General Hospital
Childbirth July 2012/Local Hospital
Childbirth June 2010/Local Hospital
Car wreck November 2006/City Hospital
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Primary Care Doctor: Dr. Medicine Facility: Medicine Family Practice Phone Number: 000-123-9876
ALCOHOL/DRUG ASSESSMENT:
Current or past history of alcohol/drug use? Yes No If Yes, complete table below. If no history, move
to next section.
Do you ever drink or use more than you intend to? Yes No If yes, how often: Almost every time
Occasionally Seldom More often lately When under stress Other:
Have you ever had to increase the amount of alcohol/drug you consume to get the same effect? Yes No If Yes, when did you first notice this change? I don’t currently drink but did in my early twenties.
I also drank quite a bit after my rape experience and this is when it escalated
Do you have a history of overdosing on alcohol/drugs? Yes No If yes, when was the last OD?
Have you ever experienced a black out? Yes No If Yes, how often: Almost every time
Occasionally Seldom More often lately When under stress Other:
Do you have a history of seizures while under the influence? Yes No
With whom do you typically consume alcohol? Friends Family N/A‐Alone Strangers Other
Have you ever experienced problems related to your alcohol use? Yes No
Legal Social/Peer Work Family Friends Financial
If yes, please describe: When I was drinking after the rape, I did so to excess. It caused a lot of problems for me at home and work. I quit drinking as part of my therapy process and have been sober since.
If yes, have you continued to drink/use drugs? Yes No
LEGAL INVOLVEMENT:
Please indicate by checking below your legal status. No Involvement Probation | Length:
Parole | Length:
Charges Pending Prior Incarceration Law Suit or other Court Proceeding
Charges: Probation/Parole Officer’s Name:
Contact #:
Additional Information:
HISTORY OF ABUSE/NEGLECT:
Have you ever been abused or assaulted? Yes No If Yes, please complete the chart below.
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Type of Abuse By Whom? At What Age? Was it Reported?
Sexual Yes No
Physical Mother childhood Yes No
Emotional Mother childhood Yes No Verbal Mother childhood Yes No
Abandoned/Neglected Mother and Father childhood Yes No
Do you feel like you are in danger now? Yes No
What else do you feel is important for us to know?
I don’t see my mother as a bad person. She’s more the product of how she was raised. I knew she loved me and I know
my dad did too. They were just “kids” playing the role of parents. I love my mother as person and hate what she has
gone through in her own life. We just won’t ever be close.
HISTORY OF VIOLENCE:
Have you ever been accused of abusing or assaulting someone? Yes No If yes, please complete chart below.
Type of Abuse To Whom? At What Age? Was it Reported?
Sexual Yes No Physical Yes No
Emotional Yes No
Verbal Yes No
Abandoned/Neglected Yes No
What else do you feel/believe is important for us to know?
STRENGTHS/RESOURCES/SUPPORTS:
What limitations do you have (if any)? Financial, no “mom” to make things okay
What strengths do you have? My kids. I’m a good mom and I love my kids more than anything. I’m a generally good person who people like to be around.
What resources do you have to help with your current problem?
My husband and his family, friends
What experiences (past & present) will help you in improving the current situation?
I know I made it through something devastating before so I can again. I know counseling helped. I know I need to seek
help from others who care. It’s just hard. There are days I think this is just too much, and I will never make it through.
What are you (and your family) already doing to improve the current situation? I’m coming to counseling. My husband is working on getting our house repaired.
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Who can you count on for support? Parents Boyfriend/Girlfriend Siblings Pastor
Extended Family Friends Neighbors School Staff Church Group
Community Services Doctor Other: Co-workers
CURRENT NEEDS/GOALS
What do you feel is your biggest need right now? Coping with Maria’s loss
What do you most hope to gain from coming to counseling? Staying afloat, being a focused and worthwhile person again.
If you were to pick three goals to work on, what would they be?
Goal 1: Working through the loss of Maria
Goal 2: Finding stability in our home life
Goal 3: Improving my outlook on life so I can plug back in at home and at work
What else would you like for us to be aware of? I was significantly impacted by my prior rape experience. I have worked hard to overcome it, but it was a violent
and emotionally, mentally, and physically devastating experience for me.
INDIVIDUAL COMPLETING ASSESSMENT
Printed Name Sabrina Hinajosa Date: Today
Signature Sabrina Hinajosa
