Delia Josan
CE – 501 B – Bases of Psychopathology
09/12/2023
INFORMAL INTAKE
Counselor Question: Name
Client Answer: Lana Jones
Q: Age
A: 45
Q: Gender/Gender identity
A: Female, she/her
Q: Marital status
A: Single, never married, no children
Q: Occupation
A: Human Resources staff; supervisory HR staff prior to commencing graduate studies
Q: Residence
A: Arlington, VA
Q: Ethnic background
A: Born in Russia to Russian mother and Nigerian father; has one sister also living in the U.S.
Q: Current living environment
A: Has been living by herself for 16 years; no pets
Q: Brief description of childhood and family dynamics
A: Client describes childhood as “happy” and does not express any trauma; parents generally lacked
open display of affection/love, but client felt cared for by her parents
Q: Description of current social life
A: Client socializes with sister and friends at least once per week
Q: Description of current support system
A: Client describes her support system as “adequate”, but displayed resistance in elaborating on the
meaning of “adequate”
Q: Description of typical daily routine
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A: 7:00 AM wake-up followed by a review of current news and tasks planned for the day; work from
8:30AM to 6:30PM; goes home after work and exercises at the gym twice per week; socializes once per
week with sister and/or friends
Q: Alcohol consumption/Drug use
A: Subject consumes alcohol sporadically and in moderation; she does not use any illegal drugs and does
not illegally use any prescription medications
Q: Financial situation
A: Client is able to support herself financially and – at a minimum – her basic needs are met. Prior to
commencing graduate studies, Client “used to not care about finances”, but she currently finds that she
must me more mindful of her spending habits due to decreased income as a result of stepping down
from her position in order to facilitate her pursuit of a graduate degree.
Q: Current stressors
A: Personal finances due to pay cut; Client describes her pursuit of her graduate degree and a new
career as a positive stressor
Q: Description of mood within past 30 days on a scale from 1-10
A: Client describes her mood at 6.5 within past 30 days, at 7.5 within the past week, and at 7.5 at the
time of intake
Q: Currently or previously in therapy or under the care of psychiatrist or other mental health
professional?
A: Client consulted the services of a psychiatrist while in college; after college, she attended sessions
with five separate therapists/mental health counselors
Q: What worked? What did not work when obtaining mental health counseling services?
A: When under the care of a psychiatrist, Client was dissatisfied with the care because psychiatrist
offered medication and Client “was not interested” then and is “not interested now”; she consequently
ceased her sessions with the psychiatrist.
When receiving mental health services from a counselor, Client appreciated that the counselor listened
and paid close attention to Client’s concerns. Consequently, Client regarded this form of mental health
care effective. However, she ceased this treatment for reasons/context she can currently not recall.
Q: Reason for seeking counseling
A: While Client is satisfied with her life (7.5 on a scale of 1-10), she wishes to be in an intimate and
committed relationship and eventually get married. She rates her feelings around the lack of a
significant other at a 7 on a scale of 1-10. Her goals in therapy consist of working on exploring her
personal background and contributing factors to her lack of being in a relationship. Client would like to
explore her attachment style and how that relates to her relationships.
Q: Client’s learning style/medium
A: Client is not opposed to “therapy homework”. She is mainly a visual learner but is not opposed to
learning through reading or listening.
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Delia Josan
09/18/2023
ASSIGNMENT
BEHAVIORAL HEALTH ASSESSMENT
Visit Type: In-person
Medical # reviewed and patient identity confirmed.
Behavioral Health: Cooordinated Care Privacy Notice was reviewed by the member and a
copy of this notice was given to her.
Confidentiality and its limits were reviewed today.
Proactive Care recommendations were reviewed with the patient. Patient seen alone with:
DELIA JOSAN
Patient: LANA JONES is a 45 yr old year old single female of Caucasian (Russian) and African
(Nigerian) descent. She self-referred to behavioral health.
Patient attended the session alone.
Chief Complaint: relationship and attachment issues; depression; professional burnout.
Date of Onset: 1 yr ago; depression since teens, off/on
Duration/ onset of Problems: Sudden after ending a relationship, which client found difficult to
deal with; client ended the relationship; Depression occurred gradually during teens, throughout
college, to present
History of present illness (HPI) : no present illness
Current and Past Psychiatric Symptoms:
Client is currently not experiencing any depression symptoms, but she feels that her depression
needs to be prevented as it is likely to reoccur based on her history.
Patient reported previous or current Mental Health Diagnoses: depression (unknown
subtype) with recommended medication by a psychiatrist in her teens and throughout college
How are the symptoms impacting daily activities: no current depression, so no impact;
relationship and attachment issues also do not impact daily activities at this time. Client would
like to commence therapy as a method of prevention of any potential depression in the future.
Depression Symptoms seen in – loneliness, disconnected at times from community, insomnia,
low self-esteem
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Mania seen in – no mania symptoms currently;
Anxiety Symptoms seen in – no anxiety at this time
Psychosis symptoms seen in: no psychosis; Client reports some excessive rumination after
most recent break-up
Eating Disorders seen in – no diagnosed eating disorders; Client reports that she “used
[excessive] food and wine in the past as a coping mechanism” in, but managed to self-correct
once effects of binge eating were visible (weight gain); Client started to exercise regularly and be
more mindful of her nutrition.
Other symptoms reported in Mental Treatment History and Outcomes:
IP Treatment: none
Past OP MH Treatment: Patient seen by one psychiatrist during her teens; since then,
consulted with five separate therapists. Most recent course of therapy was 6-9 months in duration
and stopped one yr ago
Outcomes of Mental Health Treatment: When under the care of a psychiatrist, Client was
dissatisfied with the care because psychiatrist offered medication and Client “was not interested”
then and is “not interested now”; she consequently ceased her sessions with the psychiatrist.
When receiving mental health services from a counselor, Client appreciated that the counselor
listened and paid close attention to Client’s concerns. Consequently, Client regarded this form of
mental health care effective, which is the reason why she would like to resume care as a
preventive measure. Client ceased her most recent mental health counseling course one year ago.
Psycho-Social History:
Patient was raised in: Russia, Nigeria, and North Carolina (12 y/o). Client has lived in the U.S.
since. Residing in VA for the past 20 years.
Siblings: 1 sister
Current Relationships: single, never married
Children: none; two voluntarily terminated pregnancies
Education: B.A., currently pursuing graduate studies in art history
Housing Arrangement: living alone
Employment: yes
Currently Employed: full time + student
Employed field: Human resources
,
Financial: can support herself; not financially dependent on any outside sources (friends,
family); financial health has decreased due to having to step down from her supervisory position
in an effort to better facilitate her current studies.
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Family History of Death by Suicide/Homicide: No/No
Family History of Mental illness: sister suffered from mild anxiety during college; resolved
Family History of Substance Use: Yes, alcohol, father
SUBSTANCE ABUSE
Alcohol, stimulants, cannabis, prescription meds, crack, heroin, tobacco, caffeine:
Client consumes alcohol sporadically and in moderation, 1-2 month; 2 drinks/event; wine and/or
mixed drink
Current? History? How much, how often, has caused problems? : No problems at present; as
previously discussed, Subject has engaged in excessive consumption of food and wine as a
coping mechanism, but she was able to cease these behaviors without outside assistance
Do you/are you able to drive? : Yes
Legal History: none
Guardianship: n/a
Motivation for Change ( if Co-occurrent): “quite motivated” because Client is in her mid-40s
and she believes it is important to be in a healthy committed relationship;
Trauma/Abuse History: (sexual, physical, emotional, domestic violence )
Domestic violence between Client’s parents; no physical abuse toward Client
MSE Mental (= mental status) – do not ask these questions; these are the counselor’s
observations:
Appearance: Client appears well-groomed and was appropriately dressed, she appears younger
that her stated age and exhibits a healthy physical appearance (normal weight)
Behavior: within normal limits, cooperative and motivated, engages easily in converdation
Demeanor/Manner: calm, collected, respectful, friendy
Speech: normal
Mood: Presentation – noabnormalities observed; client seemed in a good mood, but was also
able to articulate the reason for seeking mental health services
Affect: congruent with mood, within normal limits
Thought Process: coherent , articulates thoughts well, organized, realistic expectations
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Thought Content: able to provide a cogent history ,no evidence of perceptual difficulties
(including AVH, PTSD type symptoms with flashbacks and dissociation, and paranoid or
delusional thinking),denies suicidal ideation, plan, or intent" ," denies homicidal ideation, plan,
or intent
Attention & Orientation: oriented to time and place
Concentration: normal for interactions during session
Intellectual Functioning/Memory: not formally tested
Impulse Control: Appropriate, adequate for this appointment
Insight: adequate for this appointment
Judgment :Good/Socially appropriate
ADL’s: Patient reported ability to maintain basic ADLs appropriate for BH supports: Yes
Overall Cognitive Functioning:
Strengths:
When not depressed, Client is able to make and maintain friendships; exercise and nutrition
knowledge, which enables Client to engage in healthy activities
Weaknesses: Tends to “cut people out of” her life when depressant; Client can be hard on
herself; Client reported a short temper; when asked to elaborate, Client stated that she does not
exhibit any provoked or unprovoked outburst of anger, but rather immediately removed herself
from a situation that she feels is aggressive or not on line with her beliefs or opinions at those
times.
Please see below for current/past medical problems.
None with the exception of two voluntarily terminated pregnancies (no subsequent medical
issues as a result)
Current/Past Medical Problems: Health records indicate Patient Active Problem List: none
Current Medications: none
Medical History:
1. Allergies: none
2. Recent physical complaints: none
3. Nutritional needs: none
4. Restrictions on physical activities: none
5. Past serious illnesses and or hospitalizations: none
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6. Serious illnesses and chronic conditions of individual’s parents and siblings and significant
others in the same household: none
7. Restrictive protocols or special supervision requirements : none
RISK ASSESSMENT:
Suicide Attempts/Gestures/Thoughts/Plan: mild suicide ideation in her 20s related to “the
meaning of life”, but never planned, never acted on, short-lived; nothing since.
Recent Physical Aggression/Violence/Anger: none
Homicide Thoughts/Plan/Gestures: none
Access to Weapons: no
Protective Factors: Client reports her social support as “adequate” in that she has the emotional
support of her sister and mother. However, Client would like to grow and enhance this area;
Client reports an attitude of hope and motivation; she has had steady employment, and a steady
place to live;
no history of S.I or substance abuse
Other risk issues: none
Assessment of risk: assessed for S.I
DSM-V Diagnosis: 300.4 Persistent Depressive Disorder, mild severity
Co-occurring: Reactive Attachment Disorder DSM-5 313.89
Diagnostic Summary:
Client presents with mild depression symptoms and evidence relative to reactive attachment due
to exposure to domestic abuse, childhood environment (former Soviet Unition), failed
relationships, and difficulty forming new and lasting friendships
Treatment recommendation:
Weekly sessions with reassessment in 8 weeks;
Patient was found to be at no significant risk for danger to self or danger to others and is safe for
treatment in the outpatient level of care.
Increase self-care activities and maintain personal exercise routine.
Review the printed information in the Patient Notes.
Monitor mood and behavior closely for any changes and for any emerging or worsening of
suicidal thoughts.
Did the patient consent to treatment? Yes
The patient has consented to indifidual treatment
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Care Plan:
Visit Interventions:
coping skills, self care, explore attachments and reasons for depression
Homework Assigned: no homework at this time
We discussed the diagnosis, the reasonable treatment options and the current treatment
recommendations. An opportunity for questions was given. Client reported that she is
safe/unsafe to leave from appt.
This writer reviewed services including the available Emergency phone number, the Medical
Advice line, and Urgent Care services.
This writer also reviewed guidelines if patient has urgent concerns or in the event of an
emergency situation including calling 9-1-1 or going to the closest emergency room if Client is
an imminent danger to self or others.
Lana acknowledged understanding of these services and plan.
The undersigned reviewed AHC guidelines if concerns or in the event of an emergency situation
including a referral to the closest ER if any symptoms worsen, suicidal or self-destructive
thoughts occur and cannot be managed safely, or a danger to self or others.
Information in Visit Notes was reviewed with the patient.
Length of session: 50 minutes
Follow-Up Appointment: Once per week for 8 weeks; Client was informed to contact the
undersigned if she has any questions or concerns or requires further assistance.
Signature, title, date
Delia I. Josan
LPC
09/12/2023
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ASSESSMENT WRITE-UP
Client is seeking mental health counseling services due to past history of depression and
“relationship issues”. Depression symptoms are currently not present, but Client is taking a
preventive stance and would like to receive counseling in order to possibly avoid depression in
the future. Her depression stemmed mainly from her perception and belief that she should
improve her relationship skills and widen her social support. Client is in her mid-40s, single,
never married, and would like to find a partner whom she can enter into a committed relationship
with.
Client would also like to explore any potential “attachment issues” stemming from her
upbringing and exposure to domestic violence between her parents. Subject believes that
exploring these issues might offer insight and potentially provide her with skills to better handle
her future platonic and romantic relationships.
Upon intake assessment and discussion with the Client, weekly individual therapy sessions were
recommended. These weekly sessions are to occur for a period of eight weeks followed by an
assessment and adjustment of the treatment plan, if necessary.
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