UCSD The Breakup Characters Worksheet

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Individual Adult Intake Form Demographic Information Date: 5/11/2023 Client Name: Date of Birth/Age: Religion: Marital Status: Gender: Language(s)Spoken Place of Origin: Referred by: Length of time in Presenting Complaint: History of Problem: Ethnicity: CURRENT SYMPTOM CECKLIST Place a checkmark next to the item describing patient’s current symptoms Depressed Mood Fatigue/Low Energy Mood swings Aggressive Behavior Oppositional Behavior Somatic Complaints Poor Concentration Agitation Generalized Anxiety Social Isolation Hyperactivity Panic Attacks Appetite disturbance Binging/Purging Laxative/Diuretic Use Significant Weight Loss/Gain Drowsy Sleep Disturbance Self-mutilation Sexual Dysfunction Sexual Trauma Victim Obsessions/Compulsions Guilt Elevated Mood Paranoid Ideation Psychomotor Retardation Phobias Worthlessness Delusions/Hallucinations Conduct Problems Irritability OTHER: Onset Date Frequency Prior Psychotherapy or Psychiatric Treatment: (Include all medications prescribed in treatment) Medical Concerns or Diagnosis: (include medical history and current medications) Current Use or History of Substance Abuse Legal History (Probation, divorce, custody, arrest, etc) Family History (consider this for parents) Parents: Father: Mother Age Occupation Education General Health If Deceased – For how long? Marital Status Childhood Family Experience:(Describe patient’s childhood experience including verbal or physical abuse if any) Family Mental Illness History: Family Medical Conditions History: Family Substance Abuse History: Support System: Education and Employment Information: Patients Current Coping Strategies: Diagnostic Impression: Treatment Plan
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Individual Adult Intake Form
Demographic Information
Date: 5/19/2023
Client Name: Gary Grobowski
Date of Birth/Age: Not explicitly stated in the film, but he appears to be in his late 20s or early 30s.
Religion: Not explicitly stated in the film.
Marital Status: In a relationship at the beginning of the film, but breaks up with his girlfriend, Brooke.
Ethnicity: White/Caucasian
Gender: Male
Language(s) Spoken: English
Place of Origin: Chicago, Illinois
Referred by: Not applicable (since this is a fictional character).

Presenting Complaint:

Gary Grobowski is a complex character with a number of strengths and weaknesses. He initially
appears to be emotionally immature and unable to fully commit to his relationship with Brooke,
his girlfriend. Gary tends to prioritize his own needs and desires over those of others, often
neglecting Brooke's feelings and expectations. He also struggles with communication, frequently
failing to express his emotions and desires in a clear and constructive manner. This leads to a
breakdown in the relationship and eventual breakup. However, as the film progresses, Gary
begins to show signs of self-awareness and growth. He recognizes his role in the breakup and
takes steps to improve himself, including seeking therapy and attempting to make amends with
Brooke. Gary's willingness to take responsibility for his actions and work on his issues suggests
a potential for personal growth and change. Overall, Gary is a complex character who struggles
with emotional maturity and communication but shows potential for growth and selfimprovement. A therapist could potentially work with him to help him develop more effective
communication skills and increase his capacity for empathy and emotional regulation.

History of Problem:

In the film "The Breakup," Gary Grobowski's history of problem centers around his difficulty
with emotional intimacy and communication in his romantic relationships. At the beginning of
the film, Gary is in a relationship with Brooke, but their relationship is strained due to his

inability to fully commit and prioritize her needs. Gary often neglects Brooke's feelings and
expectations and fails to communicate his own emotions and desires in a clear and constructive
manner. This leads to a breakdown in the relationship, and they ultimately break up. Following
the breakup, Gary struggles with feelings of regret and attempts to win Brooke back, but his
efforts are often misguided and fail to address the underlying issues that led to the breakup. It is
not explicitly stated in the film, but it is possible that Gary has experienced similar patterns of
relationship difficulties in the past. Overall, Gary's history of problem involves difficulty with
emotional intimacy and communication in romantic relationships, which has led to a pattern of
unsuccessful relationships and a sense of dissatisfaction with his personal life.

CURRENT SYMPTOM CECKLIST

Symptom
Onset Date
Frequency
Depressed Mood
N/A
Throughout the film
Mood swings
N/A
Throughout the film
Agitation
N/A
Throughout the film
Poor concentration
N/A
Throughout the film
Irritability
N/A
Throughout the film
Social Isolation
N/A
Throughout the film
Guilt
N/A
Throughout the film
Worthlessness
N/A
Throughout the film
Appetite disturbance
N/A
Throughout the film
Sleep Disturbance
N/A
Throughout the film
Fatigue/Low Energy
N/A
Throughout the film
Obsessions/Compulsions N/A
Throughout the film
Sexual Dysfunction
N/A
Throughout the film
Binging/Purging
N/A
Throughout the film
Somatic Complaints
N/A
Throughout the film
Hyperactivity
N/A
Occasional
Aggressive Behavior
N/A
Occasional
Oppositional Behavior N/A
Occasional
Panic Attacks
N/A
Occasional
Drowsy
N/A
Occasional
Sexual Trauma Victim N/A
Not Applicable
Delusions/Hallucinations N/A
Not Applicable
Phobias
N/A
Not Applicable
Psychomotor Retardation N/A
Not Applicable
Conduct Problems
N/A
Not Applicable
OTHER
N/A
Not Applicable

Prior Psychotherapy or Psychiatric Treatment:(Include all medications
prescribed in treatment)
It is not explicitly stated in the film whether Gary Grobowski has undergone prior psychotherapy or
psychiatric treatment, nor is any medication mentioned. Therefore, there is no information available
about any previous treatments he may have received for mental health concerns.

Medical Concerns or Diagnosis:(include medical history and current
medications)
There is no information provided in the film "The Breakup" (2006) about Gary Grobowski's medical
history or any current medications he may be taking. Therefore, it is not possible to provide any
information about medical concerns or diagnoses for this character.

Current Use or History of Substance Abuse

In "The Breakup" (2006), there is no explicit indication that Gary Grobowski has a current
history of substance abuse. However, there are a few instances in the film where he drinks
alcohol, sometimes to excess, as a copi...


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