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.
