Term Paper on "Counseling Assessment Candy Barr Client ID Number"

Quoted Instructions for "Counseling Assessment Candy Barr Client ID Number" Assignment:

Condense this to 5 pages. I will send the original vignette and a sample of what it is to look like when completed.

Client Name: Candy Barr Client ID Number: 55555

Gender: Female

Date of Birth: 05-05-1974 Client’s age: 28

Date of Assessment: 05-25-2006 Time of Assessment: 2:30 p.m.

Time Spent: 1.30 hours

Identifying Information: Ms. Barr is a 28 year old Caucasian referred by the human resource department where she is employed for depression. This ***** by observation would assess if Ms. Barre’s body weight appear to be average for her height and age. This ***** would observe the color of Ms. Barre’s hair and eyes. This ***** would like to ask Ms. Barre what identifying marks i.e. scars and tattoos that she has.

Chief Complaint: When asked why she thought she was referred to this ***** by the Human Resource Department. Ms. Barre 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 was referred to this ***** by the Human Resource Department where she is employed. Ms. Barre admits that she has been a “little short tempered” lately. Ms. Barre reports that she noticed her short tempered moods started around the time last year when she was promoted at work. Ms. Barre 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. Barre reports that in an attempt to correct the issue of not having her work completed on time she has increased the number of hours she is working from 40 to 90 hours a week.

Social Development History:

Father: Ms. Barre reports her father and grandfather were alcoholics. This ***** would like to know more about the current or past substance abuse with the father and grandfather. This ***** 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. Barre reports her maternal side of the family has “anxiety”. This ***** 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 ***** 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 ***** would have asked what Ms. Barre’s education level is. This ***** would like to know if she is involved in an educational or training program.

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

Independent Living: The vignette mention Ms. Barre home life in passing providing information that she drinks at home at night and alone. The vignette did not provide any additional information. This ***** would like to know where Ms. Barre 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 ***** would like to know if the client came as a condition to maintaining her employment. This ***** would like to know if there are any legal problems pending.

Social Network: The vignette mention Ms. Barre 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. Barre enjoys. This ***** would like for Ms. Barre 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 ***** would like to know whom Ms. Barre feels most comfortable confiding in.

Previous Treatment:

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

Substance Abuse: Ms. Barre reports that she does not have a history of substance abuse but admits that her father and grandfather were alcoholics. This ***** would like to know any current or past substance abuse history in the family i.e. birth family, adopted family, and foster family. This ***** would like to know if Ms. Barre’s friends or family has raised concerns regarding her substance abuse. This ***** would like to explore in depth the drinking habits of Ms. Barre. This ***** would like to know how much, how often and what she drinks. This ***** 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 ***** would like to know if Ms. Barre ever felt the need to cut down on drinking or to stop and couldn’t. This ***** would like to know if Ms. Barre reduction in activities that she enjoys is a result of her drinking or the result of working or both. This ***** would like to know if Ms. Barre 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 ***** would like to know if she will drink or use today when she leaves the office. This ***** would like to know if she can abstain on her own and when was the last time she did abstain. This ***** would like to know how she managed to abstain. This ***** would ask questions to determine how supportive Ms. Barre’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 ***** would ask questions to find out if Ms. Barre has had any hospital admissions.

Psychotropic Medications: The vignette implies that this is Ms. Barre’s first visit for mental health issues and is not taking any psychotropic medications. This ***** 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 ***** would like to explore this in dept with Ms. Barre.

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

Family Psychiatric History: Ms. Barre 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 ***** would like to explore in depth the drinking habits of Ms. Barre. This ***** would ask questions to assess if Ms. Barre has had problems in the past with alcohol in the past.

Present Use: Ms. Barre stated in the past that she would have a glass of wine to assist her in falling asleep and to quite her mind. Ms. Barre 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. Barre reported that she is now up to a full bottle of wine at night to assist her in falling asleep. Ms. Barre reports drinking everyday of the week. Ms. Barre denies that her drinking has interfered with her life in any manner. Ms. Barre denies any side effects of the alcohol or any withdrawal symptoms. Although Ms. Barre 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. Ms. Barre denies that she has a problem with alcohol and does not want the issue of her drinking discussed in therapy. This ***** would like to know how much, how often and what she drinks. This ***** 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 ***** would like to know if Ms. Barre ever felt the need to cut down on drinking or to stop and couldn’t. This ***** would like to know if Ms. Barre reduction in activities that she enjoys is a result of her drinking or the result of working or both. This ***** would like to know if Ms. Barre takes any other drugs or medication in order to sleep or make her feel better and if so how much, how often and the reasons why.

Mental Health Symptoms:

Mental Status: This ***** would like to ask Ms. Barre if she ever thought of harming herself or someone else. If yes, did she have a plan and when was the last time she thought about harming herself or someone else? This ***** would like to know if she has ever harmed anyone intentionally. If yes, does she have a plan and when was the last time she harmed someone else. This ***** would observe if Ms. Barre physical characteristics such as clothing, hair color, eye color, mannerisims, interaction with her and include general observations about the person appearance, behavior and social interaction. This ***** would describe Ms. Barre’s motor activity. This ***** would describe Ms. Barre’s mood. This ***** would describe Ms. Barre’s affect. This ***** would describe Ms. Barre’s self concept. This ***** would describe Ms. Barre’s speech. This ***** would describe Ms. Barre’s thought process. This ***** would describe Ms. Barre’s thought content. This ***** would ask questions to test the Intellectual Functions: Sensorium – Orientation to determine if Ms. Barre’s intellectual functions with sensorium in person, place, time, and situation. This ***** would ask Ms. Barre where you are. (City, state, and location). This ***** would ask Ms. Barre what is today’s date? (month, date, year). This ***** would ask Ms. Barre why is she here in my office today? This ***** would ask Ms. Barre to spell the word “world” backwards. This ***** would score on number of letters in correct order then record the score. This ***** would ask Ms. Barre to begin at 100 and count backwards by 7, this ***** would stop after 5 calculations, and then record the score of numbers right. This ***** would test Ms. Barre’s memory by asking Ms. Barre to repeat the following words – rose, fish, bread. After minutes I would ask Ms. Barre to repeat these words again. This ***** would ask Ms. Barre to list 4 recent presidents of the United States. This ***** would ask if Ms. Barre has difficulty remembering things in the remote past. This ***** would ask Ms. Barre if she has experienced hallucinations, delusions, or other apparent thought disorders. This ***** would estimate intelligence through evaluation and questioning Ms. Barre. This ***** would ask questions to test judgment and control. This ***** would ask Ms. Barre a series of question that would indicate if Ms. Barre has good, average, or poor judgment and self control. This ***** would ask question to test Insight in the same manner.

Initial Impression:

Disposition:

This ***** in completing the Mini Mental Status Exam (MMSE) with Ms. Barre found that she had scored “No Apparent Impairment” according to the vignette.

Ms. Barre has experience symptoms related to a stressful event which is one criteria for Adjustment Disorder. Ms. Barre has development of emotional and behavioral symptoms in response to an identifiable stressor her promotion which occurred within 3 months of the onset. Ms. Barre has distress in excess of what would be expected from the exposure to the stressor, significant impairment in social, occupational functioning, and the symptoms are not caused by bereavement. Ms. Barre displays symptoms of having difficulties adjusting to starting a new position. As a result she has experienced difficulty with her mood and behavior for several months after the announcement of her new position. She is more irritable than usual. The primary goals of treatment related to the Adjustment Disorder are to relieve these symptoms and assist with achieving a level of adaptation that is comparable to Ms. Barre’s level of functioning before the new position.

Ms. Barre has not provided enough information for this ***** to determine if she meets criteria for Alcohol Dependence, Alcohol Abuse, or other alcohol induced disorders.

Ms. Barre displays symptoms of Type A Personality. She has an insatiable desire to achieve goals. She has a strong desire for advancement and recognition. She has a desire to multitask under time constraints, a perfectionist in completing task, and always concerned about the work that needs to be completed.

Ms. Barre reports that she has difficulty sleeping and uses alcohol to help her sleep. Ms. Barre reports no other medical problems.

It is recommended that Ms. Barre participate in a minimum of one, one-hour weekly mental health individual counseling sessions for 16 weeks to address her mental health issues. In these sessions, Ms. Barre will be reinforced about the need to identify triggers which exacerbate her stress levels, develop alternative coping strategies, and work toward reducing her anxiety symptoms. In addition this ***** recommends that Ms. Barre participates in MAST and SASSI-3 to gather data for this ***** to evaluate if Ms. Barre needs additional treatment for substance abuse. This ***** also recommends that Ms. Barre participate in a psychiatric evaluation to determine if medications would be clinically appropriate at this time. If a psychiatric evaluation is unable to determine appropriate clinical diagnosis, further psychological testing may be required.

*****