BIO – PSCHO – SOCIAL ASSESSMENT - PATRICK WHO CARES

Felicia McCaw
Sociology/Psychology 300
Interviewing &
Counseling

Felicia McCaw’s Exercise Assignment

Individual Practice
Therapist – Felicia McCaw
CLIENT – PATRICK WHO CARES

BIO – PSCHO – SOCIAL ASSESSMENT


I. IDENTIFYING INFORMATION

NAME OF CLIENT – PATRICK WHO CARES

BASIC DEMOGRAPHICS - Hispanic and Black

II. PATIENT’S HISTORY OR PROBLEM

Client’s words – I don’t k now what exactly is wrong with me, but I am diagnosed as Schizophrenic with Psychotic Disorder Bordering on Mania.

Other’s word – According to parents this has been an ongoing issue for a long time with son (client).

Diagnosed as being Schizophrenic with Psychotic Disorder Bordering on Mania

III. REFERRAL SOURCE

Mental Health of Saginaw County

IV. HISTORY OF PROBLEM

Post - natal – No problem prior to the age of 12
Psychological problems started at the age of 13

V. DEVELOPMENTAL HISTORY

Post- natal – No problem prior to the age of 12

Developmental Milestone – Client has trouble assimilating basic material and has problems just dealing with normal life. Recommend that this person be watched and kept under close scrutiny by parents or an adult. Early trauma (traumatic experience in life) has not been determined to be a factor of illness or a cause of this mental disorder.

School Adjustment – Client has trouble at school interacting in a school setting and with other students.



Felicia McCaw
Sociology/Psychology 300
Interviewing &
Counseling
Page 2

Therapist – Felicia McCaw
CLIENT – PATRICK WHO CARES
BIO – PSCHO – SOCIAL ASSESSMENT
(continued)

V. DEVELOPMENTAL HISTORY
(continued)

Early Trauma – No evidence of trauma experienced by client provided or has been substantially documented.

VI. FAMILY HISTORY AND SITUATION

Client is a native of Saginaw, Michigan. His parents are both alive his father (Black) is 50 and his mother (Hispanic) is 45 right now. He has two siblings – sister is 26 and his brother is 20 and is the third and last child. Client has a steady good relationship with parents and siblings who are very supportive, caring and loving. There is no attitude problems noted with parents or siblings noted nor are there any psychological problems or disorders noted in family or with parents and siblings. Every person seems to be normal in family with no outstanding characteristics of a disorder affecting them. All of his nuclear family get along with each other and are supportive of each other and very supportive and protective of client. They are very comfortable with their mixed culture and no problems appear evident with the children’s mixed heritage. Nothing appears to be affecting the other kids as far as psychologically. The sociological and family conditions reflect they are situated in the middle class and are not in poverty with no significant problems ongoing on. Both parents have worked since they were in their early twenties and they are well established. There is nothing to indicate or determine that this is a dysfunctional family that would signify developing a mental disorder or in the past to cause client to develop a psychological disorder this child is the only one affected by this malady.
All are very religious and attend church every Sunday. The parents have good values and were very stern with children and both were prone to making sure children get an education and job. Parents started work early and they reinforced those values toward being a contributor to society and the values of work to their children. Client’s parents kept their standards and expectations high and the idea of family supporting each other…their expectations for children is to finish school, get an education, get a job, get married and focused on having a well adjusted family.
Client’s parent and sibling’s economic status is that they are positioned and financially stable and are very social and frequent parties and have friends.

VII. SOCIAL HISTORY AND CURRENT SITUATION

Financial – Client is on Supplemental Social Security

Employment and Military – Client is incapable of working and has never been employed or in the military.

Higher education/training – Client ever has no higher education or training.


Felicia McCaw
Sociology/Psychology 300
Interviewing &
Counseling
Page 3

Therapist – Felicia McCaw
CLIENT – PATRICK WHO CARES
BIO – PSCHO – SOCIAL ASSESSMENT
(continued)

VII. SOCIAL HISTORY AND CURRENT SITUATION
(continued)

Community and Neighborhood - He is allowed to attend some community events but always with someone.

Friends - Client has difficulty establishing social contacts but he does have some friends on the same level as him but he does have some who do not psychological disorders who know of his condition and they are supportive of him.

Recreational activities – Client likes sports, nintendo games, baseball and any physical activity.

Cultural information and Conflicts – Client has no conflicts but has a little trouble mingling.

Substance use and abuse – Client has no history of substance use or abuse. Client on medication he has to take daily…

Legal problems – Client has no legal problem but is under the guardianship of parents.

Religion – Client goes to church every Sunday with his parents and siblings.

Hobbies/Interests – Client has no fixed hobbies but plays sports and reads some.

Military history – Client has no military history.

VIII. SEXUAL AND PARTNERING HISTORY

Relationships (current and past) – Client has no sexual partnership in the past or present.

Violence – Client has no violent history.

IX. MEDICAL HISTORY

Client medical history is documented with his family doctor that list his beginning treatment, e.g., inoculations, regular medical appointments and treatments. Clients has had no surgery, any major illnesses in life and is not allergic to anything. Client does have full medical coverage.



Felicia McCaw
Sociology/Psychology 300
Interviewing &
Counseling
Page 4

Therapist – Felicia McCaw
CLIENT – PATRICK WHO CARES
BIO – PSCHO – SOCIAL ASSESSMENT
(continued)

X. MENTAL HEALTH HISTORY

Client has extensive records at Mental Health Services of Saginaw County where he has been treated for years. Client was treated at White Pine Pyschological and subsequenltly discharged and referred to Mental Health Services for continual care.

XI. OBSERVATIONS IN CURRENT INTERVIEW (MENTAL STATUS EXAM)

Client is as noted by observation in this current interview (mental status exam) right now is still on the same level that he was before and I have seen no extensive change in his behavior. I have seen nothing to progress further he is still able to mingle in society there is nothing wrong or a significant change in behavior but he needs to be kept under care (not scrutinized every second) but someone needs to be there to make decisions for him.

Facial expression – Worried Dress – Normal – Clean Speech – Amount Reduced
Motor Behavior – Agitation Thought Process - Blocking
Interview Behavior – Irritable
Withdrawn
Dependent

XII. STRENGTHS AND RESOURCES

Client is a nice young man who is very personable and whose problems are not noticeable
unless there is constant interaction which will allow you to view his problem.

XIII. IMPRESSIONS/SUMMARY/FORMULATION

I am impressed with the young man (client) and impressed with his family (parents and siblings) that are very supportive of him and take good care of him and make sure that everything is okay in his life. I would love to continue to be his therapist to assist him further to maybe help progress a little further past his diagnosis and reroute his thinking or whatever so that he could be diagnosed with a lesser mental disorder and to keep a progress report on his past and present status. Also, I would like to monitor his interaction with people so that he does not become further stressed and become more mentally ill. That would be my plan of action to monitor him and see where he is at and just keep touching bases with him and see if there is that can be done so he can merge into society.