Form 24 Initial Assessment—Adult

Client’s name: Pattie Finkle Date: October 9, 2022

Starting time: 9:00 am Ending time: 10:00 am Duration: 1 hour

PART A. BIOPSYCHOSOCIAL ASSESSMENT

1. Presenting Problem Pattie came into the Mental Health office today stating she has not felt “happy” since the birth of her fourth

child. She said “All I want to do is stay in bed. I don’t want to hold the baby or care for my other children.

I cry all the time.”

2. Signs and Symptoms (DSM-5-TR based) . . . Resulting in Impairment(s)

(Include current examples for treatment planning, e.g., social, occupational, affective, cognitive,

physical)

Client reports the following symptoms: sadness, sleeping (a lot), no appetite, difficulty

concentrating, “wishing she was dead”, aches and pains all over her body with no direct cause

(i.e. too much exercise, heavy lifting).

She is a full-time administrative assistant to the President of a large company. She has been

employed there for ten years with minimal absence. She is currently on maternity leave. She has

been married to her husband and father of her children for 12 years. She reports their relationship

has been strained and that she and her husband barely speak or touch. These symptoms did

present in the birth of her first child but “no so much” in the second and third child.

She reports that she “cannot get anything done” and will not accept help from her mother or

husband. Her husband told her to come and get help or get out.

3. Family mental health history: Client states there are no “crazy” people in her family. She reports that her

brother died in a car accident when she was 10 years old. She was raised by a single mom and reports that

her “uncles” were very affectionate and paid her a lot of attention.

4. Current Family and Significant Relationships (See Personal History Form)

Strengths/support: none at this time

Stressors/problems: Mother and husband are “always getting on my case”

Recent changes: Birth of 4th child six weeks ago

Changes desired: “for anything to get better”

Comment on family circumstances: Does not want a divorce or to leave her family

5. Childhood/Adolescent History (See Personal History Form) (Developmental milestones, past behavioral concerns, environment, abuse, school, social, mental health)

Developmental history includes two siblings (one deceased). The other sister is estranged and does not talk with mom due to “personal issues” with her mom’s boyfriends. Client attended protestant church regularly and until recently remains active member in church. Client reports she was an average student in both high school and college. She met her husband at college and got married after she got pregnant. Did not seek any counseling for family divorce, brother’s death, sister’s estrangement, or after the birth of her first child.

6. Social Relationships (See Personal History Form)

Strengths/support: Best friend works with her at the bank.

Stressors/problems: financial stressor due to maternity leave and cost of childbirth.

Recent changes: Husband works double shifts as shipping manager for a large retailer

7.

Changes desired: Wants to spend more time with husband when they are not fighting.

Cultural/Ethnic (See Personal History Form)

Strengths/support: Faith is important part of her life (husband is a member of another faith)

Stressors/problems: Does not have the energy or desire to go to church or socialize with church members

Beliefs/practices to incorporate into therapy: Believes in the power of prayer

9. Legal (See Personal History Form) Reports that she is behind on all of her bills. States that she and her husband got behind during COVID and

could not catch up. Wants to file for bankruptcy.

Status/impact/stressors: Utilities shut off periodically, no internet for work from home,

10. Education (See Personal History Form)

Strengths: BA in business

Weaknessess: always wanted to get her MBA

11. Employment/Vocational (See Personal History Form)

Strengths/support: FT employed with benefits

Stressors/problems: has to return to work as maternity leave is ending soon

12. Military (See Personal History Form) na

Current impact: ________________________________________________________________________

13. Leisure/Recreational (See Personal History Form)

Strengths/support: previously enjoyed walking around neighborhood and attending children’s sporting

events.

Recent changes: children do not have winter sports and have “virtual days at school two days a week”

Changes desired: “don’t know”

14. Physical Health (See Personal History Form) Gained 75 pounds during pregnancy. High blood pressure and gestational diabetes after fourth pregnancy

Physical factors affecting mental condition: all over aches and pains- tired all the time.

15. Chemical Use History (See Personal History Form) n/a

16. Counseling/Prior Treatment History (See Personal History Form) n/a

PART B. DIAGNOSTIC INTERVIEW

MOOD (RULE IN AND RULE OUT SIGNS AND SYMPTOMS: VALIDATE WITH DSM-IV-TR)

Predominant mood during interview: flat affect with intermittent crying

Current Concerns feels sad all the time

MENTAL STATUS

(Check appropriate level of impairment: N/A or OK signifies no known impairment. Comment on

significant areas of impairment.)

Appearance N/A or OK Slight Moderate Severe

Unkempt, disheveled (___) (__x_) (___) (___)

Clothing, dirty, atypical (__x_) (___) (___) (___)

Odd phys. characteristics (__x_) (___) (___) (___)

Body odor (__x_) (___) (___) (___)

Appears unhealthy (___) (__x_) (___) (___)

Posture N/A or OK Slight Moderate Severe

Slumped (___) (__x_) (___) (___)

Rigid, tense (__x_) (___) (___) (___)

Body Movements N/A or OK Slight Moderate Severe

Accelerated, quick (__x_) (___) (___) (___)

Decreased, slowed (___) (___) (__x_) (___)

Restlessness, fidgety (__x_) (___) (___) (___)

Atypical, unusual (__x_) (___) (___) (___)

Speech N/A or OK Slight Moderate Severe

Rapid (___x) (___) (___) (___)

Slow (___) (__x_) (___) (___)

Loud (_x__) (___) (___) (___)

Soft (___) (___) (_x__) (___)

Mute (_x__) (___) (___) (___)

Atypical (e.g., slurring) (__x_) (___) (___) (___)

Attitude N/A or OK Slight Moderate Severe

Domineering, controlling (__x_) (___) (___) (___)

Submissive, dependent (___) (__x_) (___) (___)

Hostile, challenging (___x) (___) (___) (___)

Guarded, suspicious (___) (_x__) (___) (___)

Uncooperative (__x_) (___) (___) (___)

Affect N/A or OK Slight Moderate Severe

Inappropriate to thought (___x) (___) (___) (___)

Increased lability (__x_) (___) (___) (___)

Blunted, dull, flat (___) (___) (__x_) (___)

Euphoria, elation (__x_) (___) (___) (___)

Anger, hostility (__x_) (___) (___) (___)

Depression, sadness (___) (___) (__x_) (___)

Anxiety (___) (___) (___) (___)

Irritability (__x_) (___) (___) (___)

Perception N/A or OK Slight Moderate Severe

Illusions (___x) (___) (___) (___)

Auditory hallucinations (__x_) (___) (___) (___)

Visual hallucinations (__x_) (___) (___) (___)

Other hallucinations (__x_) (___) (___) (___)

Cognitive N/A or OK Slight Moderate Severe

Alertness (__x_) (___) (___) (___)

Attention span, distractibility (___) (___) (_x__) (___)

Short-term memory (__) (___) (__x_) (___)

Long-term memory (_x__) _) (___) (___)

Judgment N/A or OK Slight Moderate Severe

Decision making (___) (__xx_) (___) (___)

Impulsivity (___) (___) (___) (___)

Thought Content N/A or OK Slight Moderate Severe

Obsessions/compulsions (___x) (___) (___) (___)

Phobic (__x_) (___) (___) (___)

Depersonalization (__xx_) (___) (___) (___)

Suicidal ideation (___) (___) (_x__) (___)

Homicidal ideation (__x_) (___) (___) (___)

Delusions (__x_) (___) (___) (___)

Estimated level of intelligence: _____Average to above average_

Orientation: __x__ Time __x__ Place ___x_ Person

Able to hold normal conversation? ___x_ Yes ____ No

Eye contact: minimal_

Level of insight:

____ Complete denial ___x_ Slight awareness

____ Blames others ___x_ Blames self

____ Intellectual insight, but few changes likely

____ Emotional insight, understanding, change can occur

Client’s view of actions needed to change: “get it together or die”