The client is a 36-year-old, White female. She is recently divorced with two children, 13 and 15. Client lives in West Phoenix where she has lived all her life. She completed high school and has taken some college classes. She works as an administrative assistant in a elementary school district.
Presenting issue: (reason for services now – provide list of all known presenting issues) Client continuously feels stressed and overwhelmed. She wants to go back to school but is not sure how she can afford it. She is also worried she won’t have time for classes with working and taking care of her children. She is constantly stressed about finances as her ex-husband does not pay child support consistently. She would like to find a job that pays more but does not feel like she has many options. Client also reported she does not know what she would want to study if she does go back to school. Strengths and resiliency: (List all observed or reported strengths and history of resiliency) She currently supports her family, often with only her income. She is organized. She takes good care of her children and is a consistent source of strength for them. She is reliable, responsible, and want to grow. Client has a support system in her extended family and friends. She is also very connected with her faith.
Past psychiatric history (Could be “none”, or a description of past difficulties to include whether there was prior treatment) None
Substance use history (Could be “none” or a description of past difficulties to include whether or not there was prior treatment) Client will drink on occasion with friends. She reports she will have approximately one glass of alcohol every two to three weeks. Client reports she does not use any additional substances and has not in the past.
Developmental history (List Childhood events that may be impacting client now) Client reports she grew up in a “normal” family. She stated her parents would argue occasionally “but nothing crazy”. She was raised in the same community where she currently. Client reports she currently works in the same school district where she went to school. Biological/Physical factors (List genetics, family history, prescribed medication, physical conditions – details of any item that pertains to current situation) Client states she is good health without any current health problems. She is not currently on any medication. Her father recently had a heart attack and is back home. She exercises approximately three times per week by “doing the stairs” or running.
Psychosocial factors (List environmental factors, relationships, support system, safety – brief description of each area) Think PIE Client has an older brother and an older sister. Her parents as well as her siblings and their families all live in West Phoenix in the same community she does. She has contact with her family multiple times per week and feels supported by her family. Client stated she does feel like there are things she can’t talk to them about at times because they can be very opinionated. Client reported she will talk to her friends about things she feels she cannot talk to her family about. She has been divorced for approximately two years. Her ex-husband will pay child support occasionally and when he does it is never the full amount. He is currently giving the money directly to her and not through the court system. Client reports she enjoys her job, both the work she does and the people she works with. She stated it does not pay enough. She stated she applied for AHCCCS for her children but was denied because she makes too much. She said she cannot afford to put her children on her insurance plan through her job because it would cost $400 per month.
Coping Mechanisms (List Adaptive AND maladaptive strategies used) Client reported she will talk to her sister or her friends when she is stressed out or overwhelmed. She stated she will also pray when she is at her “limit”. Client also stated she will occasionally shop on Amazon or binge watch TV when she is overwhelmed.
Cultural identity (List description of how client describes self, cultural view of current situation, other strengths or liabilities due to culture) Client identifies as White. She also identifies as “Conservative Christian”. Neither her mom nor her sister went to college or worked outside of the home. Client reports that this can cause some tension in her relationship with them when she talks about wanting to go back to school.
Spiritual identity (List description of how client describes self, spiritual view of current situation, concept of higher power, other strengths, or liabilities due to spirituality) Client reports finding strength in her spiritual beliefs. She states she attends church twice per week. She states she knows God will get her through her current situation, but she is unsure what steps to take or what to do next
