CLIENT #1 17 YEARS OF AGE BIRACIAL FEMALE, ALWAYS WELL-GROOMED AND WELL DRESSED,

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Jul 28, 2022

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CLIENT #1
17 YEARS OF AGE BIRACIAL FEMALE, ALWAYS WELL-GROOMED AND WELL DRESSED, PETITE BUILD, APPEARED HER HER,NORMAL SPEECH AND APPROPIATE EYE CONTACT AS ALWAYS. NO REPORT OF SELF-HARM OR HARM TO OTHERS, NO HAULLATIONS, ANGER. SHE WAS WITHIN NORMAL LIMITS, HAS HAD PANIC ATTACKS IN SESSIONS WHEN EXPRESSING HERSELF TO GET SO MUCH OUT. DOES NOT KNOW ANY OF HER BLOOD RELATIVES. MOTHER IS ASIAN AND NATIVE AMERICAN AND FATHER IS HAITIAN. BIRTH MOTHER IS DECEASED AND FATHER IS NO WHERE TO BE FOUND. NO KNOWN REPORT OF MOTHERS PSYCHOLOGICAL HISTORY ONLY KNOWN THAT BIOLOGICAL FATHER IS AN ALCHOLOIC AND DRUG ADDICT.
CLIENT IS PHYSICIAN REFERRED
DIAGNOSIS: GENERALIZED ANXIETY DISORDER(F41. 1), PANIC DISORDER (F41.0), SOCIAL ANXIETY DISORDER (F40.10),AND MILD DEPRESSIVE DISORDER (F32.0)
DIFFERENTIAL DIGNOSIS: ADJUSTMENT DISORDER
IN THE BEGINING ASSESSMENTS ADMINISTERED:Hamilton Rating Scale for Anxiety. SCORING 3 WHICH IS SEVERE AND BECKS DEPRESSION INVENTORY SCORING A 12 FOR MILD MOOD DISTURBANCE.
ADOPTED AT BIRTH BY BIRTH MOTHER’S BEST FRIEND
IT WAS EXPECTED THAT MOTHER WOULD NOT SURVIVE BIRTH, EVERTHING WAS JUSTIFIED IN LIVING WILL/POWER OF ATTORNEY PRIOR.
SHE HAS 3 SIBLINGS THOUGH NOT OF SAME PARENTS FROM HER ADOPTED PARENTS, SHE IS THE YOUNGEST.
ISOLATED, HOLDS EVERYTHING IN
NOT SOCIABLE IN THE BEGINING, NO FRIENDS, WORRIED SHE WAS ODD, WORRIED SHE WAS NOT LIKED OR ADMIRED.
CLIENT BECAME MORE SOCIABLE WITH MEDICATION TREATMENT (LEXAPRO) PRESCRIBED BY HER PHYSICAN ALONG WITH COVIGNTIVE BEHAVIORAL THERAPY (CBT)SHE IS RECEIVING CURRENTLY. CLIENT GAINED FRIENSHIPS AND BECAME MORE SOCIALE AS OTHERS WITH HER IN ADDITION TO BEING INVOLED IN EXTRACURRICULAR ACTIVITES IN SCHOOL THOUGH ALL OF THESE GOALS BEING MET IN HER SENIOR YEAR.
CLIENT TENDS TO HOLD ALL EMOTIONS IN, WHEN COMES TO THERAPY SHE LETS EVERYTHING OUT, EXPRESSING HERSELF FULLY.
CLIENT RECENTLY CAME IN EXPRESSING INCREASE IN ANXIETY AS SHE JUST RECENTLY GAINED CONFIDENCE, INDEPENDENCY, FRIENDS, INVOLVMENT IN SOCIETY AND WITH GRADUATING AND STARTING COLLEGE IT IS AS IF SHE HAS FEARS OF STARTING OVER AGAIN. CLIENT EXPRESSED HER PARENTS MAKING HER GO TO A COLLEGE A FEW HOURS FROM HOME FOLLOWING FAMILY TRADITIONS. SHE FEARS GOING AND HAVING TO MEET AND LIVE WITH A STRANGER WHICH SHE FEARS BUT ALSO UNCOMFORTABLE WITH THOUGH HER PARENTS STATED SHE CAN LEAVE IF SHE DOEN NOT LIKE IT. sHE FEELS AS THOUGH SHE HAS TO START ALL OVER AGAIN AND IT IS JUST GIVING HER ANXIETY…CLIENT ENCOURGED TO FOLLOW UP WITH PHYSICIAN AND TO PRACTICE SELF-CARE, ANIEXTY MANGEMENT.
——————————————————————————————————————————————————————————
CLIENT NUMBER # 2
42 YEAR OLD HISPANIC FEMALE. PARENTS ARE DIVORCED, FATHER WAS ABUSIVE TO MOTHER. hER GRANDMOTHER TOOK HER IN AND RAISED HER. NO FAMILY HISTORY OF MENTAL HEALTH ISSUES. SHE IS MARRIED TO HER HIGH SCHOOL SWEETHEART AND THEY HAVE 2 KIDS TOGETHER. THEY HAVE HAD MARITIAL ISSUES WHERE THEY HAVE SEPERATED FOR A SHORT TIME BUT DAUGHTERS DIAGNOSIS HAS BROUGHT THEM BACK TOGETHER AND STRONGER. SHE IS PHYSICAN REFERRED AND WAS INITALLY PRESCRIBED ANXIETY/DEPRSSION MEDICATION (ZOLOFT) THOUGH CLIENT EXPRESSED SHE DISCONTINUED DUE TO SIDE EFFECTS BUT DID NOT INFORM HER DOCTOR. SHE WORRIES ALOT FOR HER DAUGHTER, STATING SHE DOES NOT GET SLEEP BECAUSE SHE HAS TO CHECK HER INSULIN PERIODICALLY THOUGH WITH HER ANXIETY SHE CHECKS IT MUCH MORE OFTEN TO ENSURE SHE IS NOT RUNNING TOO HIGH OR LOW. FEELS SHE DOESN’T GET TIME FOR HERSELF AND HAS SLACKED ON SELF-CARE FOR SELF. CLIENT ENCOURGED TO SPEAK WITH PHYSICIAN IN REGARDS TO MEDICATION SIDE EFFECTS COMPLICATIONS, AND OR FURTHER MEDICATION MANGEMENT. CLIENT ALSO ENCOURAGED TO PRACTICE SELF CARE/ANIEXTY MANGEMENT AND JOURNAL EMOTIONS.
PHYSICAN REFERRED FOR GENERALIZED ANXIETY DISORDER(F41. 1), SEPERATION ANXIETY DISORDER (F93.0) AND MILD DEPRESSIVE DISORDER (F32.0). ASSESSMENTS COMPLETED WERE BECK DEPRESSION INVENTORY SCORING A 16 MILD MOOD DISORDER AND BECKS ANXIETY INVENTORY SCORING A 29 MODERATE ANXIETY.
CLIENT 2 DIAGNOSIS WERE DERIVED FROM RECENT DIAGNOSIS OF DAUGHTERS DIABETES DIAGNOSIS . THERAPY APPROACH FOR CLIENT # 2 APPLIED IN TREATMENT IS THE HUMANISTIC APPROACH
CLIENT 2 ALWAYS COME WELL GROOMED, DRESSED ATTENTIVE, GREAT EYE CONTACT. CLIENT 2 ALSO HOLDS EMITONS IN AND HEAVILY EXPRESSES HERSELF IN THERAPY AS SHE FEELS SHE DOES NOT HAVE ANYONE AT HOME BESIDES HER HUSBAND TO HAVE A CONVERSATION WITH AS SHE SEEKS COMNFORTS FROM FAMILY AND FRIENDS BUT THEY IGNORE HER AND BEGIN TALKING ABOUT THEIR ISSUES HAVING HER FEEL NEGLECTED OR AS IF THEY DO NOT CARE

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