Psychotherapy with individual




Student Name:

Part 1: Comprehensive Client Family Assessment

Demographic Information

Name Brenda S.

DOB: 4/20/1985

Age: 35

Gender: Female

Race: African American

Facility: Lin Crisis center

City: Indianapolis

State: Indiana

Presenting Problem

Constant and excessive worrying, substance use and social withdrawal

History of Present Illness

Brenda migrated from the Uganda to the United states with her family many years ago. She left a highly paying to the US with the hope of being gainfully employed in the US. Brenda is anxious and depressed because she been dealing with financial instability and dealing with divorce proceedings. According to Brenda, her Ex-husband her has not been supportive financially as she also has not been able to secure a well-paying job to provide for her needs and support her family. As a result of this, Brenda was diagnosed with depression five years ago. Brenda has been constantly anxious of what the future holds. Brenda smokes Marijuana and drinks alcohol to deal with her anxiety as a coping mechanism. According to American addiction centers (2020), the use of Marijuana and alcohol are common are the young adults.

Past Psychiatric History

Patient was told that her diagnosis is Major depressive disorder. She has been hospitalized 2 different times. She was hospitalized one time in 2015 due to suicidal ideation with a plan to overdose of alcohol. Patient was also hospitalized in 2018 for overwhelming depression and anxiety. She is also been seeking to get admitted to treatment center for her addictions because she feels living with her husband is a trigger to her depression and anxiety as well as her substance abuse. Brenda started from 5omg of Zoloft daily in 2015 which has been gradually increased and she currently on 300mg per day. Brenda stated that she sees her psychiatry every month from medication refill and for her outpatient care.

Medical …