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Extended Diagnostic Assessment Example

1 Extended Diagnostic Assessment Example Name: Marie Date of Birth: 1/28/1988 Client Identification Number: 12345 CONTRIBUTIONS TO THE Assessment Diagnostic interviews with Marie on 2/18, 2/22, and 3/1/2011 Review of available records from Hennepin County Medical Center Releases of information provided by Marie for boyfriend and mother on 2/22 Collateral information obtained from Marie s mother CURRENT LIFE SITUATION Age/Living Situation/Basic Needs/Education: Marie is a 23-year-old woman living with her mother and younger sister in an apartment in South St. Paul. She has not worked since leaving Cub Foods in 2007 and is unable to pay for basic needs, rent to her mother, or move out on her own.

Extended Diagnostic Assessment Example Name: Marie Date of Birth: 1/28/1988 Client Identification Number: 12345 CONTRIBUTIONS TO THE ASSESSMENT Diagnostic interviews with Marie on 2/18, 2/22, and 3/1/2011 ... Developmental milestones were reportedly reached at age-appropriate times.

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Transcription of Extended Diagnostic Assessment Example

1 1 Extended Diagnostic Assessment Example Name: Marie Date of Birth: 1/28/1988 Client Identification Number: 12345 CONTRIBUTIONS TO THE Assessment Diagnostic interviews with Marie on 2/18, 2/22, and 3/1/2011 Review of available records from Hennepin County Medical Center Releases of information provided by Marie for boyfriend and mother on 2/22 Collateral information obtained from Marie s mother CURRENT LIFE SITUATION Age/Living Situation/Basic Needs/Education: Marie is a 23-year-old woman living with her mother and younger sister in an apartment in South St. Paul. She has not worked since leaving Cub Foods in 2007 and is unable to pay for basic needs, rent to her mother, or move out on her own.

2 Marie completed 12 years of formal education, graduating in 2006 from South High School with a C average. She enjoyed English but struggled with math and science. She denies ever having received tutoring or special education. Significant personal relationships: Marie identifies her mother, a cousin, her boyfriend, and reluctantly her sister as supports. Despite conflicts with her mother from time to time she knows she can count on her for help and is dependent on her to meet her basic needs. Her older cousin is somewhat of an aunt figure to Marie. Her cousin has also struggled with substances in the past and Marie feels that she can be herself without worrying about criticism.

3 Her boyfriend is the only male figure that Marie trusts and worries that she could not find another boyfriend if he left her. Finally, her sister has been intermittently supportive. She sometimes escapes the arguments that Marie and her mother get into by leaving the house and shopping. This is the one area that both sisters enjoy in common but it has also been a problem area for Marie as she overspends when in a manic phase. Strengths: Marie has demonstrated the ability to develop healthy friendships in the past and will likely be able to do this again in building back her support network of family and friends she can rely on for help and understanding.

4 She is motivated for treatment and follow-up to the extent that it is connected to reaching her goals of enrolling in college and getting a job. She is optimistic about her chances for success with school and assertive in wanting to re-establish her independence. She is familiar with two of the staff at the mental health center who can help her reconnect with the community college admissions office and complete applications. Health and Spiritual Beliefs: Marie s continual strive for independence extends to her health and wellness. She is a very independent young woman who considers respect for her wishes to be the most important aspect of treatment.

5 She does not indicate a religious practice or preference. She expresses a personal belief that it is her job to look out for herself and stay healthy and safe. Her internal locus of control is an asset in engaging her in health behavior change but has been a challenge for her when others have offered help or suggested treatment as she believes she is capable of making any behavior change without assistance. Hospital records indicate that she sometimes refused treatment groups on the basis that she did not need them and could 2 manage on her own if she were discharged and allowed to prove herself. In talking with her there are signs that she is beginning to understand that her mother wants to be able to help her be healthy but may express this in ways that feel controlling to Marie.

6 She indicates that while she attended Sunday school as a child, she has not participated in formal religious or spiritual healing practices as an adult. Current Medications: She is currently on a multivitamin and Depakote. She complains that the medication slows down her thinking and that she does not like this because, it s not who I really am . She has difficulty falling and staying asleep and would like help in this area which was one of the benefits she saw with the use of alcohol in the past. REASON FOR Extended Assessment Perception of condition: Marie is able to recall very little of the events leading up to her hospitalization.

7 Her perspective once in the hospital was that she was being held against her will by people who were out to do her harm until the third day of her stay when her thinking began to clear and she realized something was not right with her. She acknowledges having a diagnosis of bipolar disorder stating, Yah, I know what bipolar is. Same as manic depression, right? She has previously admitted to alcohol and marijuana use but denied the use of cocaine which has been found in lab screening results. Her boyfriend attended her hospital discharge conference and verified the cocaine use which Marie now reluctantly acknowledges but continues to minimize.

8 Description of symptoms: She acknowledges a history of impulsive buying and spending large amounts of money using her mother s checks and credit card in order to market and distribute a rap song she was written across the county. Her mother states that when she is on medication she can be reasonable but that without it she is noticeably more easily agitated and that everyone around walks on egg shells . During these episodes Marie neglects her personal hygiene and refuses to eat. She is unable to concentrate on a topic for more than a few seconds before she is on the next topic. Her mother also describes Marie as becoming a running commentating announcer when she is off her medication.

9 According to her mother, at first people think it s a joke and funny, then they feel sorry for her, and eventually they just get tired of it and stay away. Reason for referral: She was recently hospitalized for stabilization of mental health symptoms and scheduled for outpatient follow-up as part of her discharge plan. She is seen on an outpatient basis for Assessment and integrated treatment of mental illness and substance use disorder. Marie carries diagnoses of bipolar disorder and polysubstance dependence with differential diagnosis of substance induced psychosis. Client mental health and treatment history: Marie s mother describes her daughter as being high spirited from an early age and a handful to keep track of.

10 She also reports that Marie had a great imagination that could get her in trouble with various stunts she tried as a child, including falling off a 6 foot high balcony she had climbed. She was independent at a young age, wandering the neighborhood in search of someone to play with if she was not supervised. After Marie s father left the family when Marie was 12 her mother had difficulty managing her during the summer vacation. In order to cope with being a single parent Marie s mother sent her to spend summers on her grandfather s dairy farm in Iowa where she thrived. In school she had a difficult time following rules and remaining in her seat and quiet, prompting teacher conferences in which referral for potential ADHD was often the topic.


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