CSPS-INTAKE Form2

Reason for referral/what has brought the client here? - The client was referred by their GP due to concerns about anxiety and difficulties managing emotions. Hobbies, interests, and strengths - Enjoys playing video games, drawing, and spending time with friends. Demonstrates strong artistic abilities. Family Name, occupation, relationship status, and level of contact with client: Mother: - Sarah Jones, Teacher, Married, High contact Father: - David Jones, Engineer, Married, High contact Siblings (age and gender): - Emily, 10, Female Other family supports: - Maternal grandparents are supportive and involved. Additional notes: - Client reports feeling overwhelmed by schoolwork and social pressures. Presentation Mini Mental Status Examination Appearance and behaviour: - Appears well-groomed and appropriately dressed. Behaviour is cooperative and slightly anxious. Speech activity: - Speech is clear and of normal rate and rhythm. Mood: - Reports feeling anxious and down. Affect: - Affect is congruent with reported mood; appears slightly constricted. Cognition: oriented? Y / N ; memory impairment? Short / long ; attention? - Oriented to person, place, and time. No apparent memory impairment. Attention appears intact. Thoughts: suicidality? Ideation / plan / intent / self-harm ; homicidality ; - Denies suicidal ideation, plan, or intent. Denies homicidal ideation. Delusions? Grandiose / paranoid / religious / other - Denies delusions. Perception: hallucinations? Auditory / visual ; depersonalisation / derealisation - Denies hallucinations, depersonalisation, or derealisation. Behaviour: cooperative / guarded / hyperactive / agitated / aggressive / withdrawn / other - Cooperative. Insight: good / fair / poor - Fair insight into their difficulties. Judgement: good / fair / poor - Good judgement. Presenting Problem (e.g., parent/carer and client's perspectives and areas of concern) - Client reports feeling anxious, particularly in social situations and at school. They also report difficulty managing feelings of sadness and frustration. Onset of presenting problem - Symptoms began approximately six months ago, coinciding with increased academic pressure. Goals in therapy (e.g., what would client like to achieve during therapy?) 1. Reduce anxiety in social situations. 2. Develop coping mechanisms for managing difficult emotions. 3. Improve self-esteem. Current functioning Sleep (e.g., does client fall asleep easily? Stay asleep through the night? Any nightmares?) - Reports difficulty falling asleep due to racing thoughts. Wakes up occasionally during the night. Appetite/diet (e.g., recent loss/gain of weight? Does client eat school lunches? Body image? Fussy eater? What are client’s preferred food? Any therapist support? Dietician? Review by GP/other doctor?) - Appetite is variable. Eats school lunches. No concerns about body image. Developmental History Pregnancy - Mother reported an uncomplicated pregnancy. Birth - Normal vaginal delivery. Early years Sleep: - Regular sleep patterns as a young child. Feeding: - Breastfed for six months. Attachment: - Secure attachment to parents. Developmental milestones Walking: - Walked at 12 months. Talking milestone: - Spoke in full sentences by 3 years. Toileting milestone: - Toilet trained by age 3. Sensory sensitivities/interests (e.g., textures, noise, smells) - Sensitive to loud noises. Social History Current social functioning Friends: - Has several close friends. Support network: - Strong support from family and friends. Safe people: - Parents, grandparents, and close friends. Bullying?: - Denies any bullying experiences. Peers and teachers?: - Positive relationships with peers and teachers. Other relationships?: - No other significant relationships. History of abuse, losses, separations, significant life changes? - No history of abuse, losses, separations, or significant life changes. Violence (past/present) - No history of violence. Education History Name of school and grade - Maplewood Elementary, Grade 5 Missed any days of school in the past 2 weeks? - Missed one day of school due to feeling unwell. Current academic performance - Performing well academically. Any learning difficulties/concerns at school? Reading: - No reading difficulties. Spelling: - No spelling difficulties. Maths: - No maths difficulties. Other subjects: - No difficulties in other subjects. Speech/Language: - No speech/language difficulties. Attention: - No attention difficulties. Behaviour: - No behaviour difficulties. Co-ordination: - No co-ordination difficulties. Current supports at school - Receives classroom support from the teacher. Psychiatric/Psychological and Medical History Diagnoses or traits/symptoms - Diagnosed with Generalized Anxiety Disorder. Previous therapy - No previous therapy. Suicidality (past/present)/NSSI - Denies suicidality and non-suicidal self-injury. Risks to others - No risks to others. Safety plan required? Yes No If yes, was a safety plan created/reviewed? Yes No If yes; Safety plan overview - N/A Medical history - No significant medical history. Family medical history - Mother has a history of anxiety. Forensic & Legal History Any current or pending legal or court cases: Denied Yes (discuss referral options) - Denied. Previous juvenile offenses: Denied Yes If yes, provide details & outcomes - Denied. Past/Present school-related issues: Denied Yes If yes, provide details & outcomes - Denied. Child Protection Services involvement: Denied Yes If yes, details & circumstances of any ongoing involvement - Denied. Formulation Predisposing factors - Family history of anxiety. Precipitating factors - Increased academic pressure and social demands. Perpetuating factors - Avoidance of social situations. Protective factors - Strong family support and good coping skills. Plan (e.g., initial thoughts/direction, where to go from here?) - Begin Cognitive Behavioral Therapy (CBT) to address anxiety symptoms. Psychoeducation for the client and parents. Schedule weekly sessions. Review progress in four weeks. Next appointment 1 November 2024.