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INTAKE REPORT: PART ONE
Benchmark Intake Report Part One
Identifying Information
Client name: Serenity Rivera ( 34 years)
Address: 777 Darling Way, Waterbury, CT 06705
Phone: 203-559-1111
DOB: 8/12/1989
Gender: Female
Marital Status: Single, never married
Occupation: Waitress
Work/School: Wellmore Behavioral Health
Work Phone: 475-657-8955
Emergency Contact: Nancy Rivera 475.553.3456
Date of Interview: 5/20/2023
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INTAKE REPORT: PART ONE
Reason for Referral
Serenity is a 34-year-old female who was referred by Lovelyn Smith, school advisor for
evaluation , Ms. Smith believes Serenity would do well in a summer missions’ trip.
Relevant Medical History
Serenity is overweight and has been diagnosed with polycystic ovarian syndrome. Due to
this diagnosis, Serenity struggles with infertility and insulin resistance. She has also been
diagnosed with hidradenitis suppurativa, which causes her frequent pain which has led to several
surgeries and hospitalizations. Serenity reports that her diagnosis greatly affect her self-esteem
but has been doing well recently She is currently taking 100 mg tab of metformin 2x daily to
manage PCOS symptoms. Serenity reports that her mother and maternal grandmother both have
diabetes. Her maternal grandmother has also survived breast cancer twice. Serenity’s father
passed away when she was 18 due to lung cancer. Serenity shared that the death of her father has
greatly impacted her. Her maternal grandfather passed away from lung and brain cancer. She
recently learned that her mother’s sister has heart problems. Serenity reports frequent body aches
and tension. She also reports having trouble falling asleep and stays awake until 3am most times.
Serenity states this is because she has racing thoughts and is scrolling through her phone in bed.
She has reported recent increase in blood pressure that is being monitored by her primary care
doctor.
Psychiatric Treatment History
Serenity reports that she has struggled with what she believes mental illness for most of
her life. She shared she remembers seeing a therapist as a very young age around 4 years old.
Serenity was diagnosed with ADHD at a young age and received special education services in
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INTAKE REPORT: PART ONE
school. She believes her ADHD still affects her as an adult due to having difficulty concentrating
and lack of motivation, she has not received a diagnosis for depression but states throughout
your childhood and adolescence, she has struggled with feeling down, and low self-esteem.
These feelings have followed her into adulthood. She finds herself having racing thoughts
regularly. She shared that both of her parents struggled with addiction until her teen years. Four
of Serenity’s aunts and uncles have struggle with substance abuse. Serenity shared that her
mother struggles with anxiety and depression and is currently seeing a therapist. Her mother is
also attending a weekly group for former addicts. Serenity shas seen a therapist was briefly
during her undergrad years when she had a panic attack in class. She was prescribed Xanax
during that time but no longer takes it as she did not feel she needed it. Serenity reports that her
biological brother had development delays growing up and was a late bloomer. Serenity has
received counseling from a pastor when a past partner was shot in killed seven years ago.
Serenity reports being depressed a lot at that time she did not receive a diagnosis. She was out of
work for several weeks and isolated for 3 months.
Family History
Serenity reports that she has a large family on brother her mother and father’s side. She
was predominantly raised by her mother’s side but does have a good relationship with her
paternal family. Growing up, Serenity was raised by her grandmother along with her brother who
is 6 years younger. She has a strong bond with her brother and gets together with him regularly.
Serenity grew up with many cousins on her mother’s side. Some of which lived tin her
grandmother house also. Serenity describes her grandmother as being strict. “ My grandmother
stayed on top of everything growing up. She did not miss a thing.” Serenity’s grandmother
studies as a Jehovah’s Witness which she has picked up along the way. Serenity states she is
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INTAKE REPORT: PART ONE
close to her family, but they can be dysfunction most of the time. “ My family is closeknit but
does have conflict regularly. ”Serenity reports having a close bond with two of her cousins. We
went through a lot together.” We shared rooms as kids and have been inseparable our entire
lives.” Serenity has a close relationship with her mother. Serenity reports that despite her mother
struggling with addiction until she was 14, her mother was present for important times. She also
refers to herself as a “daddy’s girl.” Serenity stated that she feels connected to her dad’s side of
the family, although she does not see them as often. Serenity’s father also struggled with
addiction but cleaned up his life before he passed away. She reports that her mom left her dad
and pot into another relationship after getting clean but never got a divorce from her father.
Serenity reports that substance abuse runs on both sides on her family with four of eight of her
maternal grandmother’s children having struggled with addiction.
Social and Developmental History
Serenity shared that she was born premature, arriving four months early. Serenity spent
three months in the hospital as a baby. She described her mother’s pregnancy as brief due to her
mother finding out she was pregnant at three months and giving birth two months later. She potty
trained quickly but walked and talked late. Serenity reports that she was shy most of her life but
was able to make friends over the years and as she has gotten older. Serenity reports being
bullied for most of her life through early adulthood. She states this continues to impact her as an
adult. In high school, Serenity was involved in clubs, loved art, and volunteered at her local girl’s
club. She also got her first job through the summer youth employment. She recently got out of a
long-term relationship with her partner of 5 years but has never been married. Serenity reports
she has had several serious relationships in the past. Serenity reports that she experienced
domestic violence from a previous partner, who was later murdered. Serenity is close with her
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INTAKE REPORT: PART ONE
mother and speaks to her regularly. Serenity is interested in starting bible study to strengthen
her faith. She reports things can get overwhelming at times but have found ways to manage.
Educational and Occupational History
Serenity attended Kaynor Tech High and received her diploma in Manufacturing
Technology. She went on to get her associate’s degree in criminal justice from Naugatuck Valley
Community College and her bachelor’s degree in criminal justice from Post University. She is
currently pursuing a master’s degree in social work at Liberty University. She is employed full
time as a mental health counselor but would like to focus on her studies. She has worked in
mental health group homes, a daycare, as well as a homemaker and companion. She has spent
2-4 years at each job. Serenity preforms well and has improved time management skills as she
has become more experienced
Cultural Influences
Serenity is a Hispanic woman, who is lower middle class. Many minority culture
stigmatizes mental illness which may affect client’s responses. English is not her first langrage
which can make communication difficult and require an interpreter.
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