INTAKE REPORT PART TWO 1
Intake Report Part Two: Mental Status Exam (MSE)
Name
School of Counseling and Family Studies, Liberty University
Author Note
Name
I have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to…….
Email:……….
INTAKE REPORT PART TWO 2
Initial Interview
Identifying Information
Client Name: Ellen White
Address: 266 Brick’s House. Princeton, NJ 08540
Phone Number: 732-763-8672
Date of Birth: 10/07/1990
Gender: Female
Marital Status: Single
Occupation: Student/Nurse aide
School/Work: Liberty University/The Discovery Institute (Rehab)
Work Phone: Emergency Contact: Elasaid (sister) 732-763-0505
Date of Interview: 01/07/2022
Reason for Referral
The client was referred by the General Mission’s Board of the Church of Pentecost for an
evaluation. The client is being evaluated to determine if she would be a good candidate for
participation in a summer mission’s trip to Kenya in a very challenging environment.
Current Situation and Functioning
Miss. Ellen works out in the morning from 6-6:30 a.m. before preparing breakfast and
lunch for work. She works from 9 a.m. to 4:30 p.m. four days a week, returns home, attends to
school activities, prepares dinner, watches television for about an hour, takes a shower, reads her
bible, prays, and prepares for bed around 10 p.m. This is how her regular day usually looks. She
handles client paperwork, manages client calendars, and helps patients with daily living activities
(ADLs) at work. Miss Ellen described her condition as hectic, at times overwhelming, but
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manageable. She enjoys spending her leisure time and weekends with family and friends, and she
enjoys church activities and other interests. She practices self-care to alleviate some of the
tension she feels. She remarked that she loves her family and friends because they make her feel
very comfortable and capable of dealing with life's stresses.
Miss Ellen appears to be in good health and to be quite knowledgeable. She stated that in
addition to her hobbies, social interactions with family and friends, and time spent on her
spiritual life, she also likes to keep a notebook in which she records her thoughts and feelings in
response to difficult situations. Miss Ellen spoke about her ability to be creative and work well
with others. She also discussed how she is often trying to please others, how she is quickly
overwhelmed by the amount of work she has to do at both work and school, and how important it
is for her to have some space for herself. She explained how micromanaging causes her to fall
apart at times. Her positive traits are listed as being diligent, dependable, accountable,
communicative, and problem-solving. The shortcomings of Ellen are described as people-
pleasing, self-criticism, and procrastination.
Relevant Medical History
Miss Ellen has no previous or present medical history, surgeries, or any form of disability.
Her deceased family members all died of natural causes. Additionally, there are no signs of any
serious major medical conditions in close family members. Ellen is not currently on any
medications; however, she does take vitamins daily to maintain her health.
Psychiatric Treatment History
Ellen has never had psychiatric treatment. She only received premarital counseling while
she was about to get married, and pastoral counseling from her church after she had to cancel the
wedding owing to her ex-fiance's questionable lifestyle. Ellen decided to cancel her wedding
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because she did not want to make the biggest mistake of her life by marrying someone she could
not trust. She stated that she had one or two counseling sessions with her pastor, as well as some
prayers and that she was able to move on with her life fast. Aside from this incident, no evidence
of psychiatric or substance abuse among her closest relatives has been found.
Family History
Ellen's mother is a 60-year-old retired teacher named Madam Fredricka White. She was
born in Ghana and moved to the United States when she was 25 years old. Eric White, the
client's father, is originally from Ireland but has lived in the United States his entire life. He is a
retired gynecologist aged 65. Ellen is the third of three children; the first is Elasaid White, a 37-
year-old nurse. She is married with twin daughters and currently resides in Columbus, Ohio.
Max, the middle child, is 35 years old and now serving in the army. He is married to Joy, and
they are expecting their first child together. Miss Ellen characterized her childhood as carefree
and enjoyable.
She discussed how her family believes in recognizing all small successes. Her childhood
was described as joyful because her family was close-knit. In fact, every occasion was a big deal,
and they enjoy spending their vacation time traveling overseas to see family members and visit
beautiful and well-known destinations. She added that upholding stringent Christian values was
one of their household rituals; although her parents were friends with them, they were stern
parents who made sure they were raised properly. Since she travels to Ghana more frequently
than her siblings, Ellen has been exposed to the rich cultural traditions of Ghana and is fluent in
the language. Her mother made certain that they never lost their roots. Ellen lives on her own,
but she sees her family frequently and has maintained a good relationship with them.
Social and Developmental History
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Ellen stated that as she grows older, she will remember her childhood as less terrible. She
was never permitted to have many friends. In addition to not getting along with the majority of
her classmates at school, she described feeling discriminated against. Ellen stated that she was
generally friends with her siblings and that she confided in her older sister. She added that,
besides her older sister, she had one or two church acquaintances with whom she got along well
since they were of the same race as her and held the same religious beliefs. She mentioned that
she had a good social life. She also stated that she never suffered socially with her self-esteem
because she was and still is quite outspoken and has an extrovert nature. She was involved in
most of school and religious activities. She loved art and music when she was a teenager.
Educational and Occupational History
During her early childhood schooling, Ellen attended a private school. After completing
her high school coursework at Franklin High School in Somerset, New Jersey, she obtained her
diploma. She had always desired to help people, so she majored in psychology in online
education at Cornerstone University for her bachelor's degree. Ellen has always worked at The
Discovery Institute, a rehab in Princeton, NJ, and continues to do so even after receiving her
bachelor's degree. She is currently enrolled at Liberty University for her master's degree in
Marriage and Family Therapy. She added that she had applied for jobs in her field of study and is
seeking for a new type of job.
Cultural Influences
Ellen combines aspects of the American and Ghanaian cultures and was profoundly
affected by her Christian upbringing. Consequently, any potential evaluation problems may stem
from a lack of cultural competence within the culture being worked with. Inadequate awareness
can result in biases and beliefs being projected onto the client, which can also be considered an
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assessment issue. These factors may also contribute to prejudice and unfairness in testing.
Respect for Ellen's multiracial cultural aspects, devoid of any presumptions of inherent
superiority on my behalf, will be required.
Mental Status Exam
Appearance and Behavior
Miss Ellen White is a single biracial female who is 5 feet 8 inches tall and of average
weight. She was well-tanned and had bright skin during the interview. She came across as really
approachable, eager to assist with the interview, and upbeat about the whole thing. Ellen was
adequately attired for the interview, wearing a flowery dress with a belt, flat shoes, and cute
earrings. Her lengthy braids were neatly pulled back into a ponytail and secured with a hair band.
She had a mild perfume smell and looked very neat in her appearance. She maintained eye
contact throughout the interview, answered questions directly, and kept her focus when speaking
and being spoken to. Additionally, her receptive language and speech patterns were normal. She
moved normally, nothing out of the ordinary. Throughout the entire conversation, she exuded a
sense of comfort, and her psychomotor activity was typical. The subject did not look strange or
out of the ordinary, and there were no signs that she was using drugs or alcohol at the time of the
observation.
Sensorium and Mental Ability
Miss Ellen showed signs of being focused and awake during the interview. Although she
has not been formally assessed, her vocabulary and reported college GPA indicate that she has
above-average intelligence. She had outstanding communication skills and used words with
maturity. She had no difficulty recalling earlier experiences or recalling thoughts throughout the
session. Her recent distant memory was superb. There was no ambiguity or difficulty in
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answering questions about her recent or distant memories or mathematical calculations. Her
mental faculties were evidently bright and attentive. There were instances when interruptions
caused her to lose her focus and occasionally stray from the topic of conversation. She has
difficulties arranging her details while responding to a question with a story.
Thought
Miss Ellen presented a coherent and logical train of thought. There was no tangential
thinking, idea flight, or loose associations observed. The nature of the thoughts seemed to be
within typical bounds. Except that, she had signs of anxiety at several points during the interview
and would speak in a way that suggested she was under pressure, but overall she believed the
subject to be within reasonable bounds. There was no indication of any hallucinations, delusions,
paranoid thoughts, or ruminations. There were no reported obsessions or compulsions.
Sensory Motor and Perceptual Processes
Perceptual and sensory-motor functions looked to be within reasonable limits. Ellen was
able to accurately replicate the image of a flower vase. There was no indication of any auditory,
perceptual, or fine motor tremor. She occasionally fidget with her hands, but it never got out of
hand.
Affect and Mood
Ellen appeared relaxed and informal during the interview. When we first met, she
grinned, laughed, and smiled when needed. Her voice's variation seemed fitting as well. When
she became enthused about a subject, her monotone speaking tone would suddenly become
lively. When the chance arose, she frequently attempted to break the ice in the room,
demonstrating that she preferred loudness to stillness for conversation. She occasionally spoke
fast while turning her head aside, which suggested that she was feeling anxious. She denied
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having suicidal or homicidal thoughts, and she had no prior history of manic episodes. There was
no indication of a risk for aggression or impulsivity.
Self-regulation
Miss Ellen demonstrated sound judgment and impulsive control. Her responses
demonstrated maturity and wisdom when she was questioned about the different trying situations
she had to deal with throughout the years. Everything she said made sense in light of her
background and who she is today.
