Psychological Intake Assessment Jane's Case of Major Depressive Disorder

**CONFIDENTIAL** Intake Report NAME: Jane M. Smith DATE OF BIRTH: June 15, 1987 AGE: 30 years-old DATE OF INTAKE: February 5, 2018 INTAKE INTERVIEWER: Madison Brainard DATE OF REPORT: October 10, 2019 Identifying Information and Reason for Referral I. Jane is a 30-year-old woman who moved from Austin, Texas to San Diego, California last year to work at a marketing firm. Jane shares a ethnic background of German and Vietnamese. Jane is not currently in a romantic relationship. Prior to moving, Jane was diagnosed with Major Depressive Disorder, mild, recurrent. When Jane moved to San Diego, she did not continue with her therapy she was seeking in Texas. Recently, Jane decided to see a therapist in San Diego due to the onset of experiencing a relapse episode of depression. During her intake, Mrs. Smith expressed, “ I just feel like I’m not happy when I should be happy” and “ I haven't been happy for many years. Sometimes I start to think I’ve turned a corner, but then the sadness is back. It’s such a deep sadness. I feel it in my bones.” Jane as well explained that her depression prevents her from many things, she said, “ I knew it was coming back this time because I stopped enjoying anything, I can’t focus, and I feel agitated all the time.” Additionally, Jane expressed, “ Most days I can barely make it to work.” and “ I just feel like a waste of space.” ● Who was your previous therapist? What was his/her name? II. Behavioral Observations (and Mental Status Examination) A. Her hygiene revealed she was semi-well groomed with poor body odor and unkempt hair, dressed in casual business attire and appeared her stated age. (normal) B. Her speech rate was normal, rhythm was normal and volume was soft. (normal) C. “Restless, agitation, sad, depressed, and gloomy.” D. Client described her mood as “not happy;” her affect appeared dysphoric and liable-range. E. Thought process was circumstantial, at times went into unnecessary detail. Jane denied suicidal ideation. She expressed, her life doesn't have very much “purpose” or “meaning”, but denied suicidal ideation by stating she would “never harm” herself. Jane was oriented to situation, time, place and person. She was semi-future-oriented, and had no active hallucinations, delusions of paranoid ideations that were observed at the time of evaluation. (normal) F. Jane was cooperative throughout the interview. G. As a consequence, the following information is likely an adequate representation of Jane M. Smith’s past and present condition. (valid, normal interview) ● Does Jane feel like she struggles to express her emotions? ● Does Jane feel like she has anxiety about certain situations, emotions or people? ● Is there any previous ways of coping that has been successful in the past? III. History of the Current Problem(s) (or Illness) A. Janes presenting problem includes depression. She described her current stressors as feeling “ like everyone is happier than I am” and feeling like “a waste of space.” Jane expressed that she has very little reason to feel this way, “ I live in a beautiful city, I work for a good company, I make a decent living - there are good things in my life.” She claimed she does not have any friends, or a partner and spends her weekends at home. She explained, her “life doesn’t really have any purpose or meaning.” Subsequently, these stressors followed with not being able to enjoy anything, lack of focus, feeling agitated and low self esteem. B. Jane’s presenting problem of feeling deep sadness was initially diagnosed as Major Depressive Disorder. Jane was in therapy before she moved to San Diego for work, she did not continue therapy when she relocated. Over a year of living in San Diego, she just recently started to feel a relapse episode of depression. She described her symptoms as not being “happy for many years,” and it does not seem to go away. Jane said she had many high hopes for herself when she moved to San Diego, such as hiking. She went hiking once, but she went alone and it was depressing to see others smiling, laughing in groups. She does not exemplify to have many goals, feelings of purpose or meaning in her life. Due to not having a support system, close friends or activities she looks forward to. She claims to have a tough time getting out of bed, staying focused and finding interest in things that used to make her happy. C. Jane expressed no presence of suicidal ideation. She expressed she would want a relationship but she is too “dysfunction” that no one would “want to be” with her. She expressed multiple times of states of being alone, such as staying home on the weekends, binge watching netflix and thinking about leaving work once she gets there. Janes time in bed and time spent at home seem to be abnormal. Her appetite seems to be normal. Signs of hopelessness, feels of doubt and self-inequality seem to be preeminent. D. Client denied any history of urge to self harm. ● What do you think originally caused these problems to arise? ● When did you begin feeling this way? ● In what other ways does your current situation impact your daily life? IV. Past Treatment History and Family Treatment History A. See Section III. B. Previous treatment includes therapy with Doctor in hometown, Austin, TX. C. Not Available D. Not Available ● For what duration of time (i.e. years/months) did you seek help through therapy? ● Have you had any other mental diagnosis besides Major Depressive Disorder? If so what are they? ● Have you ever been hospitalized, or taken any types of medication? V. Relevant Medical History A. Not Available B. Client claims she has never had any other medical problems besides depression. C. Not Available D. Not Available ● How do you feel your overall physical health is right now? ● Do you have a primary care physician (and/or specialty physician)? ● Have you ever taken medication to help manage your symptoms of depression? If so do you remember the dosage? VI. Developmental History (skip) VII. Social and Family History A. Jane mentioned her early memories of her family, she described her mom as being a “pretty happy person, or so she seems.” Her dad has always been “more reserved”, and not the kind of guy to share his feelings or share with Jane if something was wrong. Jane has two sisters, but they do not talk. In school she did not have many friends, or individuals she would consider friends. She explained herself as “mutual outcast.” B. In school Jane got A’s and B’s and went to a local state college. She majored in Art. C. Currently, Jane works at a marketing firm in San Diego, California. She moved from Austin, Texas for this job. D. Not Available E. Not Available F. Not Available G. Not Available H. No current use of alcohol. Currently smokes cigarettes, after quitting for 3 months. I. Not Available J. No current drug use, besides cigarettes. K. Not Available ● What was your childhood like? Did you have any major experiences? ● How often do you tend to smoke cigarettes, ( i.e. one pack a day, or one pack a week)?