PCN-610 Eliza D Psychosocial Example Name: Eliza Doolittle ******** Date: ********* Age: 18 2:00p Start Time: 1:15p DOB: End Time: Identifying Information: The client is a Caucasian female with average height and slender build. The client stated that she is currently a freshman in college, majoring in engineering. The client also stated that her family resides in a small town approximately two hours away. Presenting Problem: At the onset of the session, the client stated that she had come to counseling as a result of being caught in a campus dorm with alcohol (it is an alcohol-free campus). Concerning the incident, the client stated “the RAs were called because my friends were being too loud in my dorm. When they arrived, they saw us with alcohol, and we got in trouble.” The client stated that her friends in the dorm were intoxicated but she was not, adding, “I was just buzzed” and adding that she was drinking “because they were” and “it’s just something to do.” Life Stressors: The client identified school as a life stressor, adding “things came easy to me in high school, I just figured it would be the same in college”. The client went on to state that, in addition to the difficulty in increased study requirements, she had struggles in making friends, stating, “a lot of my friends from high school have either gone to college somewhere else or are doing other things,” although the client denied feeling lonely. Substance Use: Yes No The client denied having a drug or alcohol problem, adding that she tried marijuana once in high school but “I didn’t like how it made me feel” and had not taken it since. The client stated that she was introduced to alcohol in HS when “friends asked me to drink it with them.” The client stated that “I sometimes drink on the weekends with friends,” denying drinking in excess or ever suffering symptoms of being hungover. Addictions (i.e., Gambling, pornography, video gaming) The client stated that she occasionally plays a Massive Multiplayer Online game. When asked how often the client played, the client stated “one or two times a week” for approximately “three to five hours” at a time. The client denied gambling or pornography issues. © 2015. Grand Canyon University. All Rights Reserved. Medical/Mental Health Hx/Hospitalizations: Any past mental health history or hospitalizations denied. Abuse/Trauma: The client denied any current or past abuse, although stating in passing that she did experience some level of teasing in HS, although the client denied discussing specifics. Social Relationships: The client stated that she had quality relationships, but added that she felt as though she was, at times, being taken advantage of. When asked for details, the client stated that her friends oftentimes pressure her to complete their homework, as well as often push her to “party in my dorm.” When asked if the client had ever talked with her friends about said issues, the client stated that she had not, adding, “it’s not that big of a deal.” Family Information: The client stated that she was the only child in her family, describing her mother as “kind of controlling” and her father as “a good guy.” The client went on to state that her mother required her to call approximately once a week “or else she gets worried,” adding that during HS her mother “was always asking where I was going or what I was doing.” The client stated that her parents seemed to have a strained relationship at times, stating, “when I call, I talk to my mom first, and then she hands the phone off to my dad, and he goes into another room to talk with me.” The client also stated that the two frequently complain to the client about the current status of their marriage. In the conversation, the client also acknowledged sometimes feeling as though she were “the middle man” when living at home. Spiritual: The client identified as being an agnostic. The client also stated that her parents are Irish Catholic, even though “they mostly only go to church on Christmas and Easter.” Suicidal: Denied. Homicidal: Denied. © 2015. Grand Canyon University. All Rights Reserved.
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