Clinician: Madeline Friedman, MFT Trainee Supervisor: Jan Wilson, LMFT, 50200 Submitted To: Prescribing professional Client Name: Casey Primary Concern: Evaluation for appropriate pharmacotherapy for Major Depressive Disorder and Generalized Anxiety Disorder.
Section A
Casey is a 21-year-old white, American woman. She is a 4th year university student studying education. During the school year, she lives in an apartment with one roommate who is also a student her age. When classes aren’t taking place, she lives with her family. She has a mother, a father, two brothers, and a sister. Two of her siblings have struggled with their mental health. She has been in therapy and saw a psychiatrist…show more content… The client returned to therapy hoping to work on her anxiety and depression as it is affecting her ability to complete her schoolwork and accomplish her goals. The client reports rarely drinking alcohol, partially because it stings and makes her drowsy. Almost exclusively only having alcohol when it is to take a sip in religious settings for prayers. The client reports having no history of substance abuse. My process for developing a diagnosis was administering the PHQ9 and GAD7 to Casey. Then I went over and discussed her answers to the questionnaires to get a better understanding of how her symptoms were affecting her and to what intensity. Additionally, I made sure to rule out differential diagnoses by asking specific questions relating to criteria for different differential diagnoses. For example, I asked questions…show more content… XXXX, My name is Madeline Friedman, and I am a Marriage and Family Therapist Trainee working at CalFam Counseling. Enclosed is a signed consent form for patient health information for us to exchange information about Casey. I have been seeing Casey for two and a half months for individual psychotherapy. She is able to see me on a weekly basis. I plan to continue to see her on a weekly basis unless her symptoms worsen. I have been using a Cognitive Behavioral Therapy approach to target symptom relief along with distress tolerance skills training from Dialectical Behavioral Therapy. During our last session, I recommended that she make an appointment with you to evaluate her depressive and anxiety symptoms. She is a 22-year-old White, American university student living with a roommate in an on-campus apartment. Her anxiety and depressive symptoms have been increasing over the past few months, and that’s why she reached out for therapy two and a half months ago. She feels that she has had anxiety for most of her life, with different intensities depending on external factors, and was diagnosed with Generalized Anxiety Disorder by a general practitioner at 18-years-old. Casey reported having a Major Depressive Disorder episode at 18-years-old. Symptoms of Major Depressive Disorder started up again at the beginning of the fall when school started. Her anxiety and depression are impeding her ability to do her schoolwork and therefore keep her GPA
