Counseling Assessment Candy Barr Client ID Number Term Paper

Pages: 5 (2228 words)  ·  Bibliography Sources: 0  ·  Level: College Senior  ·  Topic: Sports - Drugs

Counseling Assessment

Candy Barr Client ID Number: 55555

Gender: Female

Date of Birth: 05-05-1974 Client's age

-2006 Time of Assessment: 2:30 P.M.

Time Spent: 1.30 hours

Identifying Information: Ms. Barr is a 28-year-old Caucasian referred by her human resource representative for depression. This writer by observation would assess if Ms. Barr's body weight appear to be average for her height and age. This writer would observe the color of Ms. Barr's hair and eyes. This writer would like to ask Ms.

Barr what identifying marks i.e. scars and tattoos that she has.

Chief Complaint: When asked why she thought she was referred to this writer by the Human Resource representative, Ms. Barr stated that she referred her for depression. Ms. Barr reports that on three occasions she engaged in verbal conflict with her co-workers resulting in her being written up.

Presenting Problem: Ms. Barr admits that she has been a "little short tempered" lately, and that these moods started around the time of her work promotion last year. Ms. Barr admits that the new duties and responsibility has overwhelmed her and she is having difficulty completing any aspect of her work in a timely and "perfect" fashion. Ms. Barr reports increasing her work week from 40 to 90 hours in order to complete her work.

Social Development History:

Father: Ms. Barr reports her father and grandfather were alcoholics. This writer would like to know more about the current or past substance abuse with the father and grandfather. This writer would like to know how long had this been an issue. Is it still an issue? Did their spouse or friends ever voice concerned with their use of alcohol? What were their drinking habits like? How much, how often, and what do/did they drink. Did they ever neglect some of their usual responsibilities in order to drink? Did they ever try to cut down on drinking but could not? Did they give up or reduce important activities in order to drink?

Mother: Ms. Barr reports her maternal side of the family has "anxiety." This writer would like to know more about the current or past mental health issues with the maternal side of the family and what treatment or services helped and what did not help.

Siblings: The vignette did not provide this information. This writer would like to know if there are any siblings if so what level of involvement she has with her siblings.

Education: The vignette did not provide this information. This writer would have asked what Ms. Barr's education level is. This writer would like to know if she is involved in an educational or training program.

Employment: The vignette provided information that Ms. Barr is employed but did not provide information on type of employment, what hours she is scheduled to work, if she supervises any employees, and did not provide information on the skill set required to perform the task assigned. This writer would like for Ms. Barr to describe her current job, type of work, work environment, length of employment, attitude toward work, and how it affects her life in relation to family, leisure time, health, relationships, etc.

Marriage: Ms. Barr reports that she is separated from her husband of five years. Ms. Barr reports her husband described her as unavailable and unfriendly. This writer would like to know if Ms. Barr engages in any type of sexual behaviors that she has concerns with. This writer would like to know if family or friends have raised concerns with her sexual activity. This writer would like to know if any of these issues are a concern to be discussed in counseling.

Independent Living: The vignette mentions Ms. Barr's home life in passing providing information that she drinks at home at night and alone. The vignette did not provide any additional information. This writer would like to know where Ms. Barr is living i.e. At home, with friends, does she have a roommate, or another type of living arrangements.

Legal Problems: The vignette did not provide this information.

This writer would like to know if the client came as a condition to maintaining her employment. This writer would like to know if there are any legal problems pending.

Social Network: The vignette mention Ms. Barr in the past interacted with family and friends and engaged in activities of interest to her. The vignette did not provide details of the interaction with family and friends or activities Ms. Barr enjoys. This writer would like for Ms. Barr to describe the relationships she is involved with and how she feels about these people (e.g. family, friends, husband, co-workers, and supervisor). This writer would like to know whom Ms. Barr feels most comfortable confiding in.

Previous Treatment:

Mental Health: Ms. Barr reports that she does not have a history of mental illness or history of depression, mood instability or psychosis. This writer would like to know if Ms. Barr is taking any medication i.e. prescription, over the counter, herbal treatments, vitamins, homeopathic or traditional to evitate the depression.

Substance Abuse: Ms. Barr reports that she does not have a history of substance abuse but admits that her father and grandfather were alcoholics. This writer would like to know any current or past substance abuse history in the family i.e. birth family, adopted family, and foster family. This writer would like to know if Ms. Barr's friends or family has raised concerns regarding her substance abuse. This writer would like to explore in depth the drinking habits of Ms. Barr. This writer would like to know how much, how often and what she drinks. This writer would like to know if she has drank more than she meant to, has she ever been preoccupied with drinking, and has she neglected responsibilities in order to drink. This writer would like to know if Ms. Barr ever felt the need to cut down on drinking or to stop and couldn't. This writer would like to know if Ms. Barr reduction in activities that she enjoys is a result of her drinking or the result of working or both. This writer would like to know if Ms. Barr used any of these drugs in the last thirty days, (No use, 1-3 times, 1-2 times, 1-2 times week, 3-6 times week or daily), when she first used the drug, when did she last use the drug, how did she use it i.e. smoke, drink, inhaled, injected or other method to use; how often she used and when was the peak of her use with this drug: Alcohol, Marijuana, Methamphetamine, cocaine,

Ritalin, Heroin, codeine, hydrocodone, oxycodone, oxycotin, propoxphene, benzadiapines, benadryl, LSD, PCP, MDMA, shrooms, ecstasy, glue, paint, gasoline, prozac, or haldol. This writer would like to know if she will drink or use today when she leaves the office. This writer would like to know if she can abstain on her own and when was the last time she did abstain. This writer would like to know how she managed to abstain. This writer would ask questions to determine how supportive Ms. Barr's living environment is i.e. her home, work, community, and surrounding environment.

Hospital Admissions: The vignette did not provide information regarding any general health hospitalizations. This writer would ask questions to find out if Ms. Barr has had any hospital admissions.

Psychotropic Medications: The vignette implies that this is Ms. Barr's first visit for mental health issues and is not taking any psychotropic medications. This writer would like to ask questions to clarify if this information is correct.

Medical Illness, Medications: The vignette did not provide any information other than she is having difficulty sleeping. This writer would like to explore this in dept with Ms. Barr.

Allergies: The vignette did not provide this information. This writer would like to know if Ms. Barr has any allergies or allergic reactions to any medication.

Family Psychiatric History: Ms. Barr reports that the maternal side of the family has a history with anxiety.

Drug and Alcohol Use:

Past Use: The vignette does not provide this information. This writer would like to explore in depth the drinking habits of Ms. Barr.

Present Use: Ms. Barr stated in the past that she would have a glass of wine to assist her in falling asleep and to quiet her mind. Ms. Barr reported after a period of time she needed more than a glass of wine to create the same results that a single glass of wine use to accomplish. Ms. Barr reported that she is now up to a full bottle of wine at night to assist her in falling asleep. Ms. Barr reports drinking everyday of the week. Although Ms. Barr did admit that, on occasion she felt sick in the morning when she woke up and twice she did not remember what she did under the influence of alcohol, she denies her drinking has interfered with her life in any manner, and does not experience any side effects or withdrawal from the alcohol. Ms. Barr… [END OF PREVIEW]

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