Assignment Task: Complete the agency and client information section.
Provide a transcript of what happened during your field education experience, including a dialogue of interaction with a client.
Identify your application of specific theories, tools, and skills within the interaction.
Analyze the interaction by interpreting the client's verbal and nonverbal responses.
Describe your reactions, including what you were thinking and feeling, and/or any issues related to the client interaction.
Introduction:
Client is a 52yr old female. She is 5'7, and weighs 178 lbs., with long white and brown hair. Ms. Has a current diagnoses of Major Depressive d/o and Panic and Anxiety d/o. Ms. was referred to the SOAR program by her case manager, Ivonne Garcia. Mrs. Garcia is employed at Park Place Behavioral Health care. Ms. appeared to be wearing black t-shirt and black cargo pants, and black tennis shoes, her hygiene is fair, her nails are done in pink. Ms. during the interview was very anxious moving a lot in her chair.
Personal History:
Ms. was born Edison, NJ. Ms. lived with mother and father. A year later her sister was born. Ms. parents got a divorce when she was 7 years old. Father move out of the home and two years after that her younger brother was born. Ms. reported that there was a lot of DV in the home between mother and father prior to the divorce. At the age of 16 yrs old Ms. reported being raped by a boyfriend at the time. She reported that she was day raped at her father house. Ms. did not want to report the incident that occurred. She then found out that she was pregnant but did not inform the parents. Ms. went to school and the school found out due to word of mouth from her friend, the school told her parents. Ms. parents were supportive, boyfriend was also inform he disappeared came around once when the baby was born. Mother help Ms. raise the baby girl. At 18yr old Ms. got pregnant with her second born from her boyfriend at the time. Mother inform Ms. that she had to get married because the mother was not able to help her with another kid. Ms. got married at 18yrs old and another baby girl. At 19yrs old Ms. had her third baby girl with her husband at the time. A year later at 20yr Ms. had her fourth child that was a boy. Then at 22yrs old Ms. had her five child that was another boy. Ms. has a total of five kids. During her marriage Ms. was a victims of Domestic violence from her husband at the time. In 2008 Ms. got a divorce. Ms. does not have contact with her firstborn and or her parents lost communication with parents. Ms. Reported that her first born does not want to be in the picture due to the DV with her ex-husband and Ms. wouldn't leave. The four kids live in Florida but Ms. does not know where exactly but she talks to the boys often and they live by the panhandle. The youngest son is married and has five kids but Ms. does not know them all only two of her grandchildren from her youngest son. The other son is not married or have kids, lives with is roommate and is struggling with mental health. The two girls live in Fort Pierce. The 3rd child that Ms. had she is married and have two kids. Ms. has met her grandchildren from her daughter side. Ms. after the divorce got in a relationship of 13years and 4years ago he cheated on her and she has been single since. Ms. has been living with friends or in motels since. In 01/2024 she started getting treatment at Park Place for psychiatrist and in 03/2024 she entered in a program through Park Place that provide temporary housing.
Occupational/Educational History
Ms. finish the 9th grade and did not go back to school her grades in school was above a D and never had a fight in school. Ms. her favorite subject was Art and the subject she dislike was history. In 06/2022 Ms. worked for burger king in Kissimmee, in 12/2022 new management came and fired everyone. In 01/2023 started working for Taco Bell until 04/2023. Ms. left due to her mental health and went to Orlando Health behavioral and got baker acted due to her depression. Ms. has not worked since due to her mental health.
Legal History:
Ms. Reported when she was 35 yrs old she was arrested for DV, her ex-boyfriend went away for the weekend and when he came back he wanted to go through her personal stuff he got aggressive and Ms. bit him and he called the police. Ms. was in jail for 3days.
Substance Use:
Ms. reported back in her 20s she use to smoke marijuana and stop when she was 26yrs old. Ms. reported started drinking ay 18ys old and stop in 2023 and she was admitted into crisis unit due to her drinking excessively.
Physical Health History:
None. Ms. reported having high blood pressure now in which she has an appointment at the Osceola health department in 04/2024. Ms. had four C-sections. One natural birth, no miscarriage, no abortions.
Psychiatric History:
Ms. during her marriage she seek therapy due to the DV from her marriage, she was in therapy for a year in Jupiter, FL. Then Ms. was baker acted at Orlando Health 04/2023 and started taking medication. Ms. started treatment at park place on 01/2024 from her psychiatrist and a psychologist. Ms. has been dx with Manor depressive d/o and panic d/o with anxiety. Ms. reports not feeling nothing with the medications she is taking she reported feeling numb. Ms. gets really anxious and feels scared and then she gets into a panic attack for no reason. Ms. first notice these symptoms about 10years ago. Ms. reported that when she started feeling those symptoms she was unable to seek help due to her not having insurance. Ms. reports her triggers are being overwhelmed and thinking too much about her past. Ms. reports that now when the medication she sleeps but before then she would only sleep 4-5 hours at night. Ms. reported that she still had a hard time going to sleep but once she is sleeping she sleeps for about 6-8 hours a night.
Functional Information:
Ms. displays significant impairments in all areas of functioning, due to the symptoms of her mental illness, specifically her depression and traumatic history as a teen. Ms. has been unable to work due to her depression, anxious. Unable to trust people and have a communication with someone due to her past history.Ms. has been unable to maintain a stable employment and housing.
Understand, remember, and apply information:
Ms. reports blocking her past and it has been difficult to remember situations from her past due to the DV. Ms. reports remembering and following through written and verbal instructions when given. Ms. reports "if there were a specific event or time I did not remember I wouldn't remember if I attended or not".
Interact with other:
Ms. reports no having contact with her parents and her first born. Ms. Reports she lost contact with her parents and her first born does not want to be in the picture due to Ms. ex-husband relationship of dv relationship. Ms. reports going outside daily either by herself or with friends. Ms. reports depending on her mood she either wants to be alone or with people. Ms. reports once or twice a month she visit friends of her kids and they also come see her. Ms. reports if someone makes her angry she walks away from her situation.
Concentrate, persist, or maintain pace:
Ms. Reports not having any difficulty with concentration, Ms. reports she enjoys watching her shows, art, drawing, walking.
Adapt or manage oneself:
Ms. reports waking up at 5am and take a shower, do her morning chores, and attending group therapy until 12pm. Eats lunch at the clinic and get transportation back home. Ms. reports while at the home she either talks with her peers, make a snack and watch tv. Then goes to sleep at 9-10pm and do it daily. On weekend Ms. reports she sleeps in and sleeps until 7am and see what everyone is doing and then on Sunday she goes to church.
Summary:
Ms. is a 52yr old single female. She is experiencing chronic mental health disorder. Ms. is currently in a residential program through Park PlaceMs. has been with diagnosed Major Depressive Disorder and panic Disorder with anxiety attack. Ms. symptoms include depressed-by isolating herself in her room, anxiety-pacing up and down, tremors hands, thought process is flat.Difficulty focusing, concentrating, unable to maintain a stable employment, housing due to her mental health.