Identifying Information And Chief Complaint

BEHAVIORAL OBSERVATIONS: Ms. Copeland was alert and co-operative during the interview. During testing she appeared to motivated to perform optimally on all tasks. Her frustration tolerance was moderate. She seemed somewhat sullen, incurred during the initial portions of the testing but became more relaxed with the examiner as testing proceeded.

31 y/o AA male patient seen today for psychiatric-mental health assessment. He is awake, alert and oriented x4. He is calm, cooperative and follows commands during assessment. The patient reports he is depressed, difficulty sleeping and nightmares at night. The patient explained his depression is as a result of deep thinking from a news he received two days ago from his elder brother that his mother is ill. Stressors identified by the patient include losing his job a week ago before the news about his mother; his wife is 6-months pregnant with their first child, who currently works part-time at her present job; patient relates difficulty paying monthly bills and inability to provide adequately for his family as a man. The patient denies mood swings, suicidal/homicidal thoughts and ideation. Patient reports his spouse is at work at the moment and he does not want to put stress on his wife due to her current condition. Patient denies been hospitalized for depression or psychiatric illness; and denies family history of mental illness. Patient reports he is seeking help because he does not like feeling this way using terms of “helpless and loss of worth from his spouse”. Patient reports he needs help with his depression and nightmares before his current condition get out of hands and ruined his marriage.

There is a common belief that many combat veterans are suffering; many from invisible wounds that affect them in many ways. The challenge that the VA and other government agencies face is determining which veterans need help, there are several factors that affect this, from the individual’s desire to accept help, to the stigma that most veterans have accepted, which is “if they ask for help, they are weak.” During separation from the military it is a critical time for all soldiers, this time provides an opportunity for the military, the VA and our government to intercede and work with men and women while they are still soldiers. Veteran suicide is an epidemic, the number of veterans taking their life daily has been steadily growing, the statistic published by the VA is that twenty-two veterans end their lives every day (Suicide Data Report, 2012); steps have been taken to curb this number but the efforts have been woefully inadequate.

Though Dr. Josephs’ report looks comprehensive, it could be considered to be lacking all the information needed to conclude who the best candidate for the position is. To come up with scores, Dr. Josephs did not take into consideration the conversations the interviewer had with each candidate. Though Mr. Zimpher’s resume may have showed that he possessed all the skill she gave him credit for, those written words don’t necessarily translate to actions. It could be that he was not able to convince the interview panel that he actually possessed those skills. Mr.

The case identified involves the Mendoza family. Ramon Mendoza has been referred to an agency to obtain a counselor that specializes with clients who have medical issues. Ramon Mendoza is a 32-year old Latino male born in the United States, but his family is from Puerto Rico. Growing up, Ramon was primarily raised by his grandmother, due to his mother being underage and his father not being around. He is currently in a on and off relationship with his girlfriend, Louisa, of 6 years and has a 10 year old son. He now lives with his mother, who is his primary caregiver, his grandmother, and younger siblings. The family has been held together by his maternal grandmother, but due to the accident, there has been tension amongst the household as evidence by the change in his relationship towards his older half brother and his relationship with his younger half brother that looks up to him. On the day of September 30, 2011, Ramon sustained a gunshot wound to his neck that has resulted in C-5 quadriplegia and hearing loss. He is now paralyzed from the chest down and has limited use of his arms and no use to his legs. Ramon had abstained from treatment after being admitted to the hospital and believed that his pain and suffering would improve without the need of therapy. On November 1, 2011, Ramon was admitted to an inpatient rehabilitation center that has given him the urge to become independent. During Ramon’s rehabilitation he experienced depression, feelings of helplessness,

Chris is a 38 year old, heterosexual, masculine, Caucasian male. Chris has just recently returned home from Iraq after serving four tours. He claims to be having trouble adjusting to civilian life and reports his weakness for giving up and choosing to quit while his “brothers” are still overseas. Chris is married with two children and desires to fulfill his roles as being a husband, father, soldier, brother, son, etc. Chris believes that this is his life’s duties and God’s plan for him. Due to feelings of anger, aggression, guilt, shame, loss, anxiousness, hopelessness, and depression, a VA physician advised Chris to utilize the VA Healthcare System in order to seek appropriate treatment.

Chris is a 38 year old, heterosexual, masculine, Caucasian male. Chris has just recently returned home from Iraq after serving four tours. He claims to be having trouble adjusting to civilian life and reports his weakness for giving up and choosing to quit while his “brothers” are still overseas. Chris is married with two children and desires to fulfill his roles as being a husband, father, soldier, brother, son, etc. Chris believes that this is his life’s duties and God’s plan for him. Due to feelings of anger, aggression, guilt, shame, loss, anxiousness, hopelessness, and depression, a VA physician advised Chris to utilize the VA Healthcare System in order to seek appropriate treatment.

Unfortunately, a full medical history was not obtained because client was not oriented and also exhibited lack of awareness. Client identified being a parent, a friend, wife, and horse owner as her main life roles. In the middle of the interview process, the client showed frustrations of her inability to recall. Interview was stopped since client could not answer further questions as she became verbally disorganized and was unable to control her

Presenting Problem: This section should be a summary of the case, specifically focusing on why the client is seeking help, what his or her referral route to the counselor is, known symptoms, and possible diagnosis. Leo is a 90-year-old, heterosexual, white male with symptoms of substance use of tobacco, alcohol, depression and high anxiety. Leo was referred for counseling by his doctor because he has difficulties and the ability to care for himself.

For this assessment, I interviewed J a 35- year- old heterosexual male of Caucasian decent who served in the Army National Guard for 6 years. He was referred to HomeAgain’s Veteran’s Transitional Shelter by a Social Worker at the VA Hospital because he needed housing, employment, and drug and alcohol therapy. Before the Veteran’s Transitional Shelter was an option, he stayed with friends and described his environmental living conditions to be chaotic. He had friendships that were toxic. He looked for bad qualities such as: Were they street smarts? Could they obtain drugs? Drugs were always present, his friends would get into arguments, and there was a lack of order and structure. He mentioned at one point he was living with his family but he

Candidate was comparing his Career counselor position in the military with DVOP position and had issue I explaining how should handle the client that come to an appointment w/DVOP inebriated. The Veteran interviewed via phone because he was out of State; but did not fully research the company, rather focused on recruiting part, versus, case management. Did not know other programs/ services we provide.

SRA is a 62 year old Caucasian male who was admitted into the hospital with a right fractured femur due to falling off the porch of his home while intoxicated. He has a history of hypertension, migraines, and has had a DVT. SRA would be in the Erikson’s stage of development of generativity vs stagnation, my patient was once married and had children who he helped raise and become responsible adults. SRA found pleasure in working, gaining new knowledge, and planned ahead for retirement. Although, SRA eats healthy he hasn’t healthy life style choices as evidence of his drinking, and smoking habits. Although he was once married he hasn’t found another wife therefore, hasn’t discovered new satisfactions as a mate and found a sense of unity and intimacy. SRA hasn’t involved himself in any outside organizations. When asked about friends he stated “I only have a few, but I don’t see them very often.” This shows that he doesn’t have close friends to share feelings, and to enjoy new social activities with. SRA was born in Elk City, Oklahoma but was raised most of his life in Perryton, Texas. His family’s origin is unknown to him. SRA is currently divorced, but has 2 children from that marriage, he attended a technical school to further his education in technology received about 24 hours of college credits, SRA worked at Dal Chemical, after retirement he went to work for Radio Shaq where he spent 16 ½ years and exclaimed “ever since Radio Shaq went bankrupt I’ve been unemployed”

The patient Maria Soto presents as an able bodied 35 year old Hispanic female. She is currently unemployed and residing with her boyfriend in East Los Angeles. She falls within the low income bracket. The patient is seeking therapy for depression. In the textbook Essentials of Understanding Abnormal Behavior defines depression as a “mood state characterized by intense sadness or despair, feelings of worthlessness, and withdrawal from others.” (Sue, Wing Sue & Sue, 2005). I will also be using the Fundamental of Abnormal Psychology by Ronald J Comer to support the diagnosis and provide treatment plan for Maria Soto.

Mr. McKenzie is a 50 year-old Caucasian, male. He has no children, and no immediate family. Mr. McKenzie was a former manager at a local steel company where he was employed for 25 years. He was known for his leadership skills, and outstanding work ethic. Recently, Mr. McKenzie was referred to McLaren Hospice for support and resources, due to the death of his spouse. Mr. McKenzie stated his wife was diagnosed with breast cancer almost a year ago. He stated he thought she was going to, “beat it.” She instead, became very sick, and passd away from liver failure due to the chemtherapy. Mr. McKenzie stated he cries alone in his room with the lights off, and does not eat or drink anything for days. Headaches, insomnia, nightmares, and anxiety have become part of his daily life. He isolates himself from any form of socializing, except to drink at the bar, and feels detached from others. He stated he has been in several fights, especially while drinking in the local bar, which has led to his arrest on two occasions. Mr. McKenzie also seems angry at others, as their lives seem to continue in a positive way.

At the beginning of the interview as Mr. Lilly approached me with an intriguing professional personality. A very nice looking, physical fit man with his salt and pepper hair, Mr. Lilly’s shirt was neatly ironed and tucked in and his boots were shined. Obviously, this man was prior military displayed not only by his appearance but also in his confidence. On the other hand, Mr. Smith had the opposite impression with his dirty boots, wrinkled shirt and goofy/joking personality. His unprofessional appearance and personality caught me off guard since this interview was being conducted at 830 AM.