Prompt: Specifically, the following critical elements must be addressed: I. Biopsychosocial Summary A. Describe the problem that the client is seeking help for in this case. i. Make sure to address an

Biopsychosocial Assessment

Client Name:_Amelia yee Jones________________________________ Chart # _________________NA_____

Evaluating Counselor __Stephanie Badio___________________________________ Date ______7-4-2020____________

Please indicate “NA” if the question/section is not applicable to the client’s history. DO NOT LEAVE ANY SECTION/LINE BLANK.

Presenting Problem: (Include the client’s own words about why the services are needed, any referrals, and major stressors over the past six months.)

Amelia is a 42-year-old female who is presenting with depression issues and anxiety followed by multiple symptoms. Amelia stated, “not feeling like herself”. She also reported that she has days she can’t get out of bed, while other days she is concerned that someone is “out to get her”. Client is in need of seeing a counselor to help with effective coping skills to get out of bed and destructive thoughts. Amelia significant other also observed her staring out of space at times which can be concerning considered her symptoms. Over the past six months these are some stressors she experienced abnormal thoughts, anxiety, appetite disturbance and more. Amelia was severely bullied and mentally abused while in school between the grades 2-11th.

Past Treatment History: (Include past treatment history for substance abuse AND mental health services) Amelia was physically abused by both her father and significant other. Amelia been to counseling therapy and consulted several therapists off and on since the age of 13 years old and last one was 2006 along with psychiatric hospitalization. Amelia has participated in traditional talk therapy, EDMR, CBT, ECT, psychoanalysis, play therapy, and lmogo therapy. She has been notified by professional to take medications prescribed such as antidepressants, antianxiety, and mood stabilizers which Amelia believed was not effective because symptoms did not change.

Family History: (Include biological family members, number of children, divorce, separations, describe what it was like growing up in this family, and include substance abuse and psychiatric history of family members)

Amelia has 2 brothers and 2 sisters her father deceased at the age of 12-year-old when he was working on a construction site. Her parents were separated she did not get along well with her parents. Although her siblings live close to her, she does not have a good relationship with them except for the youngest one. Amelia has no children and has been married for 22 years by her wife. No substance abuse on Amelia part but mentioned mental health history in family history from mother, brother, and sister. Amelia described her relationship with her mother as they talk 2-3 times a day. Amelia was married at the age of 20 years old. Amelia resides in a 3-bedroom house. Both parents used drugs and alcohol. Mom is a widowed.

Substance Abuse Drug History: (Include top three drugs of choice)

1.alcohol

2. marijuana

3.NA

(List any withdrawal symptoms as reported by client (sweats, constipation, DTs, seizures, etc.):

No none withdrawal symptoms reported by client

Social History

Client’s Current Life Situation: (Summarize present living arrangements, and any current social supports)

Amelia finds it very difficult to make friends but once make friends its easy for her to keep them. Amelia has 3 close friends

Sexual Orientation:

Amelia is a CIS-female

Spiritual Beliefs: She grew up as a roman catholic and no longer practice.

Employment History

Employment: (Include longest continuous employment, type of employment, typical length of stay, present employment, and military history)

Amelia is currently employed in the American school district and client is a LPC treating children who struggles with school performance and family issues. No history of military known. Amelia has been at her current job for the past 10 years. Amelia mentioned finding difficulty maintain employment.

Education: (Note highest level of schooling completed, school performance, peer relationships, learning problems)

Amelia obtained her master’s degree graduated in 1999 she was a A/b student, excellent in math and science. Struggles in English, spelling, and reading. Amelia was diagnosed with dyslexia but was never suspended from school.

Medical Health History: (Include illnesses, surgeries, medications [OTC and prescription]. Note any current medical problems, physical disabilities, and/or eating disorders. Please include gynecological history and pregnancies):

Amelia was diagnosed with dyslexia, severe allergies and asthma, hysterectomy at age 38, broken legs as a toddler due to a car accident.

Primary Care Physician:

Name: ____PCP_____________________________________________________

Address: _123 street______________________________________________________

Phone: ____1234567899__________________________ Fax: ___NA____________________

Date of Last Physical Exam: ___NA_________________________________

Hospital of Choice: ____NA_______________________________________

Allergies: _______dust, animal, nuts, pollen,dairy_______________________________________________

Medical Medications: (Include name of medication, dose, the condition it is treating, and its effectiveness)

___anti-depressants__________________________________ ___________mood stabilizers________________________

__________________NA___________________ ________________NA___________________

_______________NA______________________ __________________________NA_________

Mental Health/Psychiatric History:

Have you ever been treated for a psychiatric illness: Yes or No

Please explain: (Include if client had been hospitalized, seen by a mental health professional, what they were seen for, and how long they were seen)

Client been to therapy at the age of 13. Seen and professional suggested medication. Amelia was seen for psychiatric issues.

Any SI/HI or plan in past or present? (Please explain if “yes”)

No known SI/HI plan by client

Psychiatric Medication History:

Legal History: (Note any charges and dates, any outstanding warrants, court dates, description of crimes, convictions, incarcerations, etc.) no legal issues or involement

• No legal issues. no

• Currently on probation. no

• Pending warrants. no

• Jail term served. no

• Court cases pending no

• Parole no

Please explain with detail any and all of the above checked:

Clients Self-Assessment of Strengths: Clients Self-Assessment of Weaknesses

1. __compassion____________________________ 1. __ability to forgive_________________________________

2. _______make sure my relationship is fulfilling for my partner_______________________ 2. _feel better about myself and be able to feel more motivated to do the things I want/ need to do. I want to be able to manage my emotions better and not let things overwhelm me. _________________________________

3. ______________________________ 3. ___________________________________

Recommendations: (This narrative section pulls all of the information together, with a clinical opinion about what the primary issues are, and what should be done to address them. Also, state potential referrals to rehabilitative, IOP, and others that are appropriate at this time.)

Client presents as a 42-year-old multi-race CIS-female who has been married for about 22 years. She got married at the age of 20 years old. Amelia was abuse mentally physically by both her father and boyfriends. Amelia has four siblings but only close to the youngest one. Amelia has been diagnosed with dyslexia asthma and severe allergies to pollen, animals, and nuts. Amelia’s father passed while on site at work left her mother as a widow. Her relationship with her mother is described as fair. Growing up she did not get along with her parents and was bullied at school. She has no legal issues although she had some issues with substance use at the age of 14 from both alcohol and marijuana. She currently has her masters and work as a LPC with children having difficulties in a school district where she been working for 10 years. She has been prescribed medication form her pcp antidepressants, mood stabilizers for her status. She struggles with several symptoms and especially lack of sleep.

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Clinician/Counselor Signature: ________stephanie Badio____________________________ Date: __________today_

Clinical Director Signature: _____________NA__________________________ Date: _____today______