Clinical Interview
Thomas Delfario
5/28/2021
Taylor Miranda
5'10
154
Brunette
Brown
Scar on left wrist
10/11/1992
28
New York, New York
123-456-7891
Single
Fire Guard
High School
None
Not practicing
Puerto Rican
Thomas Delfario grew up practicing Christianity. He no longer goes to church or practices the religion.
Milestones (on time, delays, birth complications, health/injuries, etc.):
N/A
Birth Order/Siblings:
Eldest Brother - Jesse Delfario 10/7/87
Thomas Delfario - 10/11/92
Positive Memories:
Mr. Delfario recalls baseball being a really important factor to him at this time.
He also enjoyed holidays spent because that was the time his family got to spend the most time together.
He hard time recalling postive memories during this time and kept things surface level.
Trauma/Abuse (extent of abuse, examples, perceptions of, etc.):
Mr. Delfario recalls a lot of yelling in his household. He states that his parents had short fuses
and that his mom had a short temper and would try to fight his dad often.
He states that during that time he was very scared that his father would leave.
His older brother and him would beg him to stay.
Separations/Family Relationships:
There were times where his father would come to Mr. Delfario and his brother and state that he wanted to
leave the relationship with his mother. Mr. Delfario was very young when this was taking place.
School Experiences (grades, friendships, etc.):
Mr. Delfario had a studder and had to go to a speech class that his school provided.
Mr. Delfario says that he had a good school experience and made friends easily.
Unusual Experiences:
Mr. Delfario states that no unusual experiences occured during this time.
Middle Childhood/Adolescence:
Positive Memories:
Baseball was another positive memory for him during this time.
He remembers winning the championship that year and that it meant alot to him.
Spending quality time with his family was also a great memory.
When they were able to go to Coney Island and spend time together
it meant a lot because they were struggling financially.
Trauma/Abuse (extent of abuse, examples, perceptions of, etc.): What names were you called?
There was a lot of trauma and abuse in the house. He would frequently get yelled and beat with items around
the at for mundane things. He gave examples of accidently breaking something going to
bed a minute after bedtime and it would lead to getting beat.
Separations/Divorce/Family Relationships:
Mr. Delfario's relationship with his brother was very close. He says that they were all that they
had so they knew they needed to stay together. He says his brother would have moments
where he would take out his anger and agression on him. His brother has since apologized to him
about the way he treated him.
School Experiences (grades, difficulties/friendships, etc.):
Mr. Delfario states that he feels he had a normal experience during middle school.
A positive memory during that time is that he had a teacher named Mr. B who encouraged him to grow
and showing him things outside of the classroom.
When he got to high school he became disruptive, and hyper-agressive with his peers.
His teacher's struggled to understand him and help him. He made friends easily but struggled to maintain
them due to his reputation. He says he couldn't dig deep and make connections with others.
Employment Experiences:
No employment experience
Type
at text
this here
time.
Unusual Experiences:
Mr. Delfario states that he started drinking at 12. He states that his friend's mother would provide
alcohol to him and his friends and theyy would drink. He went to his first bar at 14.
Then he progressed to smoking cigarettes and Black and Milds.
Adulthood:
Major Changes (Life, Occupations, School, Family, Marriage/Divorce, Children, etc.):
Friendships/Family and Other Relationships: How’s your relationship with Mom, Dad, now?
Mr. Delafario's relationship with his parents are better. He states that he needs to
make more of an effort to spend time but generally things are really great between them.
The resentment he once felt he's letting go of and realizing that his parents
are people to and have had their pain and struggles.
Friendships are able to be maintained and he feels that they are balanced and postive influences on his life.
Positive Experiences/Memories:
Mr. Delfario states that visint California in his young adulthood had a positive impact
because it was the first time he got to experience something outside of his neighborhood
that is filled with poverty and violence.
Traumatic Experiences/Memories:
Social Leisure Experiences:
Employment History:
Client’s statement of “Usual” or Current Occupation (obtain salary):
First Job:
Work History (include length of each job, reason for leaving, etc.)
Work Relationships:
Goals/Aspirations:
Substance Use:
Drug
How Much
How Often
First Use
Last Use
1.
_______________________________________________________________________________
2.
_______________________________________________________________________________
3.
_______________________________________________________________________________
4.
_______________________________________________________________________________
Substance Abuse Treatment History:
Related Problems (arrests, problems at work, peers, family, seizures, blackouts, etc.):
How did they finance drug/alcohol use?:
Psychiatric History:
Current Medications (include side effects and target symptoms)
Symptoms:
Prior Hospitalizations/Treatment:
Prior Diagnosis:
How do they deal with and what causes stress/anxiety?:
Family History of Mental Illness:
Sexual Development:
First Sexual Experience:
Sexual Preference/Experiences:
Current Sexual Practices (include whether gratifying or not):
History of forced sexual experiences (include ages, age of other, description of each experiences):
History of Sexual Experiences (include any homosexual experiences, age, descriptions):
Use of Sexual Aids (magazines, videos, toys, etc.):
Fetishes, Paraphilias, Fantasies, Masturbation, etc.:
Medical History:
Current medications (nonpsychiatric):
History of major treatments/surgeries:
History of head trauma (include description of each, ie., treatment, loss of consciousness, seizures,
rehabilitation, dates and lengths and facilities):
Criminal History:
Juvenile (summarize charges, incarcerations, age, trial or plea, etc.):
Adult (summarize charges, incarcerations, age, trial or plea, etc.):
Responsibility (debts, child support, money owing, payments, bankruptcy, loans, etc.)
Mental Status:
Appearance/Hygiene:
Oriented (person, place, time):
Awareness/Attention/Concentration:
Mood (statement of feeling state):
Affect (Objective expression of mood):
Thought (comment on content, continuity, fluidity):
Speech (tone, volume, clarity):
Motor (unusual movements, retardation, fluidity, gait, anxious movements, etc.)
Cognition (estimate of intelligence – memory: recent/remote/working):
Insight/Judgment:
Psychiatric Stability
How have you been feeling recently?
Depressed
Bouts of crying
A lot of energy, decreased need for sleep
Sleep
Nightmares
Appetite
Concentration
Attention
Impulsivitey
Self-esteem
Difficulty making decisions
Suicidal ideation
Suicide attempts
Homicidal ideation
Auditory halucinations (hear voices)
Are voices telling you to tell me no
Visual halucinations
Decreased need for sleep
Thoughts racing
Out to get you
Poisoning you
Communicate through the TV
Fire setting in childhood
Food hoarding in childhood (save and hide food)
Running away
Teasing animals
Bullying kids
Shoplifting
Notes: