Comprehensive Intake: BioPsychoSocial

1. Presenting Problem: The client, a 32-year-old female, expressed feelings of overwhelming anxiety and stress, stating, "I feel like I'm constantly on edge and can't relax." She wishes to address these issues in therapy. 2. DSM-V-TR based Signs and Symptoms resulting in impairments: The client exhibits social withdrawal, difficulty concentrating at work, persistent worry, and physical symptoms such as headaches and muscle tension. 3. History of Presenting Problem: The client reports that her anxiety began approximately two years ago following a job loss. Symptoms have been persistent, with episodes of increased severity during stressful periods. There is a family history of anxiety disorders. 4. Current Family and Significant Relationships: The client identifies her partner as a significant source of support but notes recent tension due to financial stress. She desires improved communication and emotional support from her family. 5. Childhood/Adolescent History: The client was raised in a single-parent household with two siblings in a low-income neighborhood. She experienced bullying in school and struggled with social anxiety. There were no reported incidents of abuse. 6. Current Social Relationships: The client has a few close friends but often feels isolated. She wishes to expand her social circle and improve her social skills. 7. Cultural/Ethnic: The client identifies as Hispanic and values family traditions. She wishes to incorporate cultural practices into her therapy. 8. Spiritual/Religious: The client is not actively religious but finds comfort in meditation and yoga. She desires to explore these practices further in therapy. 9. Legal History: The client has no history of legal involvement. 10. Education: The client completed a bachelor's degree in marketing. She excelled academically but experienced stress during exams. 11. Employment/Vocational: The client is currently employed as a marketing coordinator. She finds her job fulfilling but stressful due to high demands and tight deadlines. 12. Military: The client has no personal or family military history. 13. Leisure/Recreational: The client enjoys reading and hiking but has not engaged in these activities recently due to time constraints. She wishes to prioritize leisure activities. 14. Physical Health: The client has a history of migraines and is currently taking medication for anxiety. She reports that her physical health impacts her mental well-being. 15. Chemical Use History: The client occasionally consumes alcohol socially but does not perceive it as a problem. 16. Counseling/Prior Treatment History: The client previously attended therapy for six months, which she found beneficial in managing stress. However, she felt the treatment did not fully address her anxiety.