Session information: CIS Reese, Specialist Sabir, and Intern Czerwinski arrived at Ct's home for a Crisis Assessment. Client presents with the issue of "I've been sick for a while", "I feel like I want to hurt myself", and "I need help, I'm in denial". Client says she lost her job in Georgia due to issues with work performance, being picked on and harassed, and being hurt at work and filing for worker's compensation. Client says after the job lost that she moved to Ohio to live with her sister. Client also says she has lost people she was close to recently and that that has been painful for her. Client says she has been "going to places I'm not supposed to" while she drinks and continues to consume alcohol. She states that she does this to isolate herself. Client says she has also been physically and mentally abused as both a child and as an adult. Client says "When I look in the mirror I see nobody". Client says she experiences daily depressed mood for most of the day, diminished interest or pleasure nearly all activities, significant weight gain, Insomnia, trouble walking and moving around, Fatigue, Feelings of worthlessness, Diminished ability to think or concentrate nearly every day, and Recurrent thoughts of harming herself. Client says she was hospitalized for a suicide attempt a few years ago and saw a provider - Christen Cochran FNP-C. She was unable to provide a diagnosis. She said that for a long time now and as recent as Sunday night that she has been using Benadryl to self medicate her insomnia. She says she experiences racing thoughts, impulsivity, risk taking, and irritability. She says she has had panic attacks in the past and currently has multiple worries. Seems to have a persecutory delusion that after her worker's compensation claim, she got back to working, and everyone at her job was gossiping about her and trying to have her fired. Client says she is drinking "everyday, all-day." and that she started drinking, like how she is now, 12 or 13 years ago but that she has been drinking alcohol for a "long time". Client also mentioned that she started drinking 10 years ago so client seems to be a poor historian. Suicide risk is moderate due to the excessive substance intake. Client, aged 59, is wearing a black shirt, blue pants, red GUESS brand shoes. She is a black female, hygine seems good, no odor, hair looks washed and well kept, Ct's clothes seem clean. Client says she would be interested in an impatient clinic and says that by going she can “get away from people” and ”get some help”. suicide RISK and protective FACTORS: She does have Hx of a significant attempt, she has a positive support system, she has had multiple recent losses, Acute anxiety is present, perceived sense of being a burden is present, Active substance use, no Family hx suicide, she lives with her sister, no Access to lethal means, no Command AH to harm self/others, no Recent discharge from hospital. Ct has never served in a war zone, client has been in a serious accident at work, Ct has never been in a major disaster, no life-threatening illnesses, Ct reports physical and mental abuse before 18, Ct has not been attacked or beaten by others, ct has been in situations where she felt her life was at risk and has had family members die violently, but has never witnessed death first hand. Ct does not appear to be at risk of violence or exploitation of others. Ct does report multiple medical concerns including anemia, VB12 deficiency, kidney stones, a past hysterectmy, and not being able to wear her glasses. Ct has never been convicted of a crime. Ct says she has a really hard time with lasting relationships because "people always leave me."
Therapy Intake Note
1. Identifying Information and Reason for Visit:
Client Name: Charlotte Jane Willis
Date of Birth: 4/23/1966
Age: 59
Gender: Female
Ethnicity: Black
Date of Assessment: [Insert Date of Assessment]
Referring Individual: Pamela Harris (Sister)
Reason for Visit: Client presented for a crisis assessment due to self-reported suicidal ideation, feelings of worthlessness, and persistent substance use. Client expressed a desire for help and indicated being in denial regarding her mental health and substance use issues.
2. Presenting Problems:
Onset: Concerns began escalating approximately 12-13 years ago with increased alcohol use and feelings of worthlessness.
Duration: Client reports daily depressive symptoms and recurrent thoughts of self-harm over the last several months.
Triggers: Recent job loss, multiple bereavements (including two brothers), and perceived harassment at previous employment.
Severity: Client reported moderate suicide risk due to excessive alcohol consumption and significant emotional distress.
Functional Impact: Limited ability to engage in daily activities, reported sleeping only 3-4 hours per night, and a diminished interest in previously enjoyed activities. Client is currently living with her sister but is reportedly at risk of homelessness if she does not seek treatment.
3. Psychosocial History:
Family/Supports: Client lives with her sister Pamela Harris, and another sister, Felita. Reported feelings of being a burden to her family. Strong support system identified, including her children.
Education/Work: Client has lost her job in Georgia due to performance issues and harassment, has been in Ohio for one month. Previous social drinker status reported, with recent change to daily drinking.
Living Situation: Currently residing with sister; however, expressed concerns regarding acceptance in the household if she does not comply with treatment recommendations.
Cultural Factors: Client has articulated a strong faith in God, although feels her prayers are unanswered, which contributes to feelings of hopelessness.
4. Relevant Medical and Psychiatric History:
Medications: Client reports using Benadryl for insomnia, no current prescribed medications known.
Prior Diagnoses: Client has a self-reported history of bipolar disorder but cannot specify further details.
Treatment Response: Client has a history of hospitalization due to a suicide attempt. Previous mental health treatment history is unclear.
5. Substance Use:
Client reports alcohol use beginning approximately 10 years ago, escalating to daily use over the last few years. Describes drinking "every day, all day," with Budweiser as her drink of choice.
Client reports being unable to recall specifics regarding frequency and quantity of use, indicating possible disorganization and denial.
6. Risk Assessment and Safety Plan:
Suicidal Ideation: Client endorses recurrent thoughts of self-harm but denies a specific plan or intent at this time.
Protective Factors: Client has children and responsive siblings as potential protective factors. Expressed interest in inpatient treatment as a means of safety and recovery.
Access to Means: Client has no access to lethal means such as firearms.
Current Risk: Moderate risk due to recent alcohol consumption and expressed feelings of worthlessness. Recommended immediate transport to inpatient facility for further assessment and safety stabilization.
7. Clinical Impressions and Provisional Diagnosis:
Client exhibits signs consistent with Major Depressive Disorder, including anhedonia, insomnia, feelings of worthlessness, and suicidal ideation. Possible co-occurring Substance Use Disorder related to alcohol use is indicated.
Provisional Diagnosis: Major Depressive Disorder (MDD) and Alcohol Use Disorder (AUD), pending further evaluation.
8. Client Goals and Initial Treatment Plan:
Client expressed a desire to enter an inpatient facility to undergo detox and receive a comprehensive mental health evaluation.
Initial Plan:
Transport client to Highland Springs for an immediate assessment.
Facilitate connection with case management for ongoing support during inpatient stay.
Recommend follow-up appointments post-discharge for continued mental health and substance abuse treatment.
Discuss potential outpatient therapy options to address long-term recovery and coping strategies.
Frequency of sessions to be determined based on client’s needs following assessment results.
Encourage client to journal or reflect on feelings and experiences during treatment for self-awareness and integration in therapy.
Signature:
[Your Name], LCSW
[Your Title / Credentials]
[Date]
