draft on cultural identity
Student Counselor Today
Amelia Yee-Jones 123-45-6789
6/25/1975 42 Multi-Racial Cis-Female
Juanita Sanchez Wife
123 Here Drive, City, ST 98765 000-123-4567
X X
Amelia is seeking counseling because she is not “feeling like herself.” She reports that she has days that she
can’t get out of bed, while other days she is concerned that someone is “out to get her,” then some days she feels
like she is not being effective. Amelia’s Wife, Juanita, reports that she observes Amelia staring off into space and is
sometimes not able to “snap” her out of it. Juanita shared that she and Amelia has discussed what might be going
on, but both are at a loss.
Both Amelia and Juanita report that his has been going on periodically for as long as they have known each other
(22 years). They report no major changes, losses, or life events that seem to be related to the concerns, but they did
mentation that they lost their dog 8 months ago. Both report that the severity, frequency, and duration are getting
worse, which is why they are seeking assistance.
Review the WHODAS 2.0 for data.
Off and on since age 13, last in 2006 multiple
Amelia has participated in traditional talk therapy, EMDR, CBT,
ECT, psychoanalysis, play/art therapy, and Imogo therapy
Antidepressants, antianxiety, mood stabilizers,
The symptoms didn’t change 20
6lbs 5oz.
Amelia said her first word at 18 months, and started spoke in sentence around 2.5 Yes, no delays in walking, motor skills, cognitive function etc.
Was in a car accident at age 3, had severely broken legs and took 1.5 years to be able to walk stably again.
Good, talk every day or so. See each other 2-3 times per month. Deceased, dies when the client was 12 in a work accident (was a construction worker and fell)
James Cis -M 51 Brother, regular communication Bernita Cis-F 49 Sister, regular communication Sally MtF 45 Sister, close, daily communication Marvin Cis-M 40 Brother, regular communication
20 22 N/A
None House, 3 bedroom
Mother, Brother, and Sister all have depression and anxiety issues. Father died Master’s degree 1999
A/B student. Excelled in math and science. Struggles in English, spelling, reading. Client dx with dyslexia
American school district Client is an LPC treating students who struggle with school performance and family issues
10
Not historically, but is finding it difficulty currently
Sever allergies and asthma, Dyslexia, hysterectomy at age 38, broken legs as a toddler (car accident)
Asthma medications, Allergies pills, estrogen, aspirin, multivitamins, and vitamin D3 PCP 1234567899 123 street Dust, animal, nuts, pollen, dairy
No No
No Was severely bullied (physically, mentally, and emotionally) from grade 2-11th, father emotionally abusive to the children and mother, had a boyfriend in high school that was also emotionally and mentally abusive.
14
4
14
Alcohol 2-3 glasses week since age 14 Marijuana no longer n/a ages 14-23
3 Reading, spending time with partner, watching tv, taking walks Knitting, bike riding, aerobics Grew up Roman Catholic, no longer practicing Partner, siblings Can isolate self, does not ask for help when needed Nothing notable, lost a pet in the past year
My compassion and ability to forgive. I am also a very good partner and will make sure that my relationship is fulfilling for my partner.
I want to feel better about myself and be able to feel more motivated to do the things I want/need to do. I want to be able to manage my emotions better and not let them overwhelm me.
My partner
COUNSELOR LPC today
Counselor LMHC today
Psychiatrist MD today
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