March 30, 2017
To: John Smith, MD
100 Anywhere Street
Any City, CA 90000
From: Elizabeth Sockolov MFT Trainee
123 Somewhere Court
Any Town, CA 90000
Elizabeth@OneMindTherapy.com
Re: Jane Doe
DOB: 1/29/1985
Dear Dr. Smith,
My name is Elizabeth Sockolov and I am a therapist trainee working with Jane
Doe. Enclosed is a signed release of information that allows us to share her
information. The client is a 32 year old white female who is an undergraduate
student at Sonoma State. I have had two sessions with the client in the past
two weeks. During our last session I asked that she make an appointment
with you to evaluate her worsening psychotic symptoms.
Ms. Doe’s symptoms started two months ago when she started having the
persistent belief that her ex boyfriend was following her. She said that “she
knew he was watching her” everywhere she went. Additionally, she felt that
when she watched TV he was trying to send her threatening messages
communicated in the shows that she watches. The client reports that these
thoughts are causing her a great deal of distress and she has missed many
classes in the past two months due to her staying in her apartment because
she is scared that she will see him.
The client started experiencing these symptoms roughly a month after her
break up with her boyfriend. She said she broke up with him because she felt
increasingly worried that he was spying on her. The client felt that her
boyfriend was accessing her phone and computer remotely while she was at
school. These worries eventually led to her break up with the her boyfriend.
She says that once they broke up her she became “obsessed” with the
thought that he was stalking her and trying to communicate with her as stated
above. She is now seeking help because it has gotten to the point where she
has been missing class and recently she has started missing work as well.
The client does not have a previous diagnosis of a schizophrenia spectrum or
other psychotic disorder. However, she says that when she was 18 she can
had symptoms that were similar to how she feels now. She was about to
leave for college when she became worried that people at the school were
plotting against her. She even began hearing voices. Her parents did not want
her to see a doctor or go to the hospital but they did convince her not to go to
college. Instead, she got her associates degree closer to home. She says that
once she was less stressed and comfortably living at home with her parents
the symptoms became less invasive. She has never been hospitalized and
has never taken medication. She reports this as the only other time she was
worried about her symptoms. However, she says that during times of stress
she has had thoughts that people are plotting against her or trying to hurt her.
These thoughts usually become less intense when the life stressors are no
longer present.
The client is now single but she was with her last boyfriend for over five years.
They met at her job at sunglass hut where he was a customer. He convinced
her to try to go finish her undergraduate degree and five months ago she
began classes at Sonoma Sate. The client has no children. She has no past
history of substance abuse or trauma. She has very few friends and little
social support aside from her parents who she relies on for some financial
support as well. Her parents are conservative and she reports that it is
unacceptable in her family to seek mental heath help. She does not want her
parents to know that she has been seeing a therapist as she is concerned that
they would reject her and stop supporting her financially.
Ms. Doe was oriented by four in our sessions. Her thinking was ruminative
and delusional. She did not report any auditory hallucinations. Her mood was
highly anxious and she had trouble sitting in her seat during our sessions. She
showed a full range of affect. She says she does not have any suicidal or
homicidal ideation and that she never has in the past. Her insight is poor to
fair. She has a sense that her delusional thoughts are abnormal but she also
“cannot help believing them”. She is mainly seeking help because she wants
to be able to go to work and class without any problems.
The client has no known medical problems. However, she goes to the doctor
infrequently. I have also asked her to go to a primary care physician for a
routine check-up. She has no history of any medical conditions.
My working diagnosis is:
Delusional Disorder, persecutory type, multiple episodes, currently in acute
episode
Schizophrenifrom Disorder, with good prognostic features
Schizoaffective Disorder, multiple episodes currently in acute episode
Following your assessment I would appreciate if you would share your
evaluation with me. If you do prescribe medication please provide a list of
medication. I will help monitor medication compliance and keep you informed
about her progress and any side effects.
Please feel free to contact me if you require any additional information. I am
happy to be of further assistance to you. You can contact me at the above
address or email address. I look forward to working with you so that we can
be of the most help to Ms. Doe.
Thank you,
Elizabeth Sockolov