Biopsychosocial Spiritual Assessment
Identifying Information: Jamiela Geathers, is self-referred 24 year old African-American female. She is single and does have any children or developmental/intellectual disabilities. She is a senior at Limestone College, who is experiencing high levels of anxiety.
Present Psychiatric Illness/Symptoms: Client reports recent episode of anxiety and mood swings, temper flare ups and difficulty focusing on school work and being around large crowds of people. She also reports weight fluctuation: gaining 2-3 pounds, then losing it within the next week or so. No current thoughts of suicide or depression.
Past Hx of Treatment: Client reports a few episodes of major anxiety attacks, difficulty focusing in class and on school work. She was treated …show more content…
Marital/Relationship: Client reports never being married or even proposed to. She reports being in love twice. Once with her high school boyfriend, having brief “situation-ships” then again when she was in college. She reports having an “unhealthy relationship for years in high school” which received a sexually transmitted disease from him and was treated for a week with chlamydia. She reports being “mentally drained from her college boyfriend but stayed with him anyway”. She reports having a few physical and verbal altercations with both men and being emotionally abused.
Mental Status: Client appears to be highly functioning, cooperative and calm. There is no evidence of tremors, or tics. Her affect is appropriate to the conversation, and she is slightly anxious. Speech is low and soft. Her thoughts flow logically and seem slightly unorganized at certain points of the conversation, then she pauses and gather her thoughts to continue the conversation. There is no evidence of hallucinations or delusions. She is oriented to time, place and person. She does not place any devaluation on herself.
Summary
Identifying Information: Jamiela Geathers, is self-referred 24 year old African-American female. She is single and does have any children or developmental/intellectual disabilities. She is a senior at Limestone College, who is experiencing high levels of anxiety.
Present Psychiatric Illness/Symptoms: Client reports recent episode of anxiety and mood swings, temper flare ups and difficulty focusing on school work and being around large crowds of people. She also reports weight fluctuation: gaining 2-3 pounds, then losing it within the next week or so. No current thoughts of suicide or depression.
Past Hx of Treatment: Client reports a few episodes of major anxiety attacks, difficulty focusing in class and on school work. She was treated …show more content…
Marital/Relationship: Client reports never being married or even proposed to. She reports being in love twice. Once with her high school boyfriend, having brief “situation-ships” then again when she was in college. She reports having an “unhealthy relationship for years in high school” which received a sexually transmitted disease from him and was treated for a week with chlamydia. She reports being “mentally drained from her college boyfriend but stayed with him anyway”. She reports having a few physical and verbal altercations with both men and being emotionally abused.
Mental Status: Client appears to be highly functioning, cooperative and calm. There is no evidence of tremors, or tics. Her affect is appropriate to the conversation, and she is slightly anxious. Speech is low and soft. Her thoughts flow logically and seem slightly unorganized at certain points of the conversation, then she pauses and gather her thoughts to continue the conversation. There is no evidence of hallucinations or delusions. She is oriented to time, place and person. She does not place any devaluation on herself.
Summary