He is a 21 years old single, Asian American, heterosexual male. He is a senior at UWB studying media communication.
PRESENTING CONCERN (Reason for seeking services and related history):
He presented with depressive mood, anxiety, fatigue, difficulties to concentrate, difficulties to fall and staying in asleep, and a diminished interest in daily activities. He noted that he is not motivated to do school work that he has been barely passing his classes for the last 2 years. He reported that he has failed some of his classes within the last 2 years. He mentioned that 2 of his professors suggested to seek counseling for depression. Robert stated …show more content…
He presented with a sense of loss as he spoke about his grandfather and father's stroke.
RISK AND PROTECTIVE FACTORS (e.g., suicide history, SIB, harm to self or others, past and current):
He credibly denied having an active thought of suicide. He stated that due to his health concerns, he thinks about his mortality. He expressed having a feeling that consists of not caring if something were to happen to him. Nevertheless, he stated that he does not have any wish to commit suicide or harm himself. He also denied plan or intent of suicide. With regards to HI, he reported that he can become angry and have a thought about an impulsive act such as reckless driving or hitting others. However, he denied acting out on his thought. He did not indicate any history of violence toward others.
TREATMENT RECOMMENDATIONS (e.g., therapy modality, goals for therapy, therapeutic approach, referrals):
Due to being at the end of quarter and the level of depressed mood he displayed we agreed to meet sooner than one week interval. He would benefit from identifying his interests that would motivate him in life, a small step to begin to change some of his unhealthy habits (e.g., diet, excise, and sleep), and ways to cope with fear, depressed mood, and anxiety. A modified motivational interview may be