Name of Client ________Julia________________________________________ Date____04/18/2013_________________ Appearance:
__Well groomed __Neat X_casual _X_Unkempt __Unclean __Inappropriate __Bizarre __Unusual General Presentation:
X_cooperative __Guarded __Distractible _X_Agitated
__Clear _X_Tone (loud/soft) _X_Rhythmic _poverty of Speech __Rapid __Slow __Stutter __Pressured __Slurred Affect:
__Appropriate __Blunted _X_Melancholy __Restricted __Labile __Inappropriate __Flat Mood:
__Even _X_Depressed/sad _X_Anxious __Irritable __Angry __Elevated __Euphoric/elated __Expansive __Passive __Pessimistic __Blunted Orientation:
_11:00A.M_Time WATAGUA AND ASSOICIATES __Place Felecia McElyea__Person Intelligence Level:
x_High _average __Low __Retarded
_rational _X_Impaired __Immature _X_Impulsive
__Emotional __Intellectual __Denial __Blames Others __Blames Self _X_Slight Awareness __X Acknowledges problem Thought Content:
_X_Logical/Reality Based __Delusions __Obsessions __Tangential __Illogical __Loose Associations __Hallucinations __Ideas of reference/influence __Compulsions _X_Flight of Ideas __Circumstantial __Inhibited __Concrete _X_Abstract Comments:
Client displays justification and other denial based thinking process. She also has persistent drug use, as well as _a history of criminal activities and prostitution. Multiple suicide attempts which shows me she is a high risk client. __ ____________________________________________________________________________________________________________________________________________________________________________________________________
RISK STATUS CHECK
Violence/Abuse: (Domestic and Workplace, Child and Sexual)
Current: ___________has had several physical fights with parents recently and her sexual partner________________________________________________________________________________________ ____________________________________________________________________________________________________________ Past: ____: Client reports present-day sexual companion has a history of forcefulness and emotionally/physically mistreated her. Companion is also the birth father of the child in question and has stated history of drug abuse and criminal activity. ___________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Suicide/Homicide: (Past attempts, Prior inpatient admissions, Ideation, Intent, Attempt, Plan, Compromised ADL’s) Present Risk:____None ____Low____Moderate_X___High
1 Current: Unsettled problems and constant harmful conduct previous to the burdens of the present situations need to be considered.
Past: Prior multiple suicide attempts, past of extended depression, and violent way of life carry an existing high risk situation.
Other risks: (eating disorder, history of multiple diagnoses, non-compliance with earlier treatment, runaway): Client states she is severely depressed, can't eat or sleep, cries a lot, cannot sit in one place long, and has trouble getting out of bed. Symptoms: Weight gain/loss Sleep decreased/increased Concentration increased/diminished Interest level decreased Fear Restlessness Increased arousal Racing thoughts Irritability Avoidance Hopelessness
Strengths identified by client: ASI Composite Scores show signs of being aware of many issues, specifically in the areas of alcohol and drugs and mental functioning. Client’s Self-Directed Search Summary Code recommends the potential for critical/technical learning and skills. Additional client strengths seen by clinician: intelligent but...