Case Assessment

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Cognitive-Behavioral Case Formulation Client Name: Ms. Date: Identifying Information: middle-aged female, married with two children Mental Status Examination She appeared neatly dressed in an outfit, which was age-appropriate. She was alert and oriented to person, place, and time. The client made every effort to be open and honest. Furthermore, she maintained a cooperative attitude toward the examiner. Her mood and affect were depressed and anxious. Speech was coherent and relevant. There were no signs of a formal thought disorder as observed. Memory was intact as observed. Insight was estimated as fair to good. Problem List 1. Feeling angry, resentful, anxious •Include score on BAI at intake •Thoughts…show more content…
J Diagnosis-Axis I: R/O Generalized Anxiety Disorder Date: March 25, 2003 R/O Major Depressive Disorder V61.10 Partner Relational Problem V61.20 Parent-Child Relational Problem Diagnosis-Axis II: V71.09 No Diagnosis Relevant Childhood Data *Include information gathered in additional sessions  Core Belief(s) “I need to be in control” “I am unlovable”  Intermediate Belief(s) “If my daughter doesn’t obey me, I am not in control/she doesn’t love me” “If my husband doesn’t do what I want him to do, I am not in control/he doesn’t love me”  Compensatory Strategy(ies) Anger outbursts, place blame on others, and avoid immediate expression of feelings to husband    Situation 1 Daughter hides in closet, which causes them to be late to school Situation 2 Daughter refuses to go to bed Situation 3 Husband spends night playing with model trains 
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