Stephanie 21 year old African-American female One child Sophomore at community college Job / family related issues Received counseling with Region III
Intake Assessment Background information Thinking about withdrawing from college Depressed about home / social life Beck Depression Inventory (BDI-II) Level of Depression The Substance Abuse Subtle Screening Inventory (SASSI-3) Alcohol / drug abuse or misuse
Intake Assessment Initial meeting with client Background information Beck Depression Inventory (BDI-II) Conducted during 2nd session with client 21 item self report instrument 4pt scale ranging from 0-3 for each item The Substance Abuse Subtle Screening Inventory (SASSI-3) 26 Frequency questions, 67 true / false questions, 10 scales: 2 for questionnaire and 8 for true / false
No serious medical issues were reported Diagnosed with depression last year Currently on low dosage medication Reports to Region III Speaks with a counselor concerning her academic, career, and family support system
The client reported no history of her family members having psychiatric issues. The client did report issues of alcohol and drug use from previous family members.
Problems begin occurring during high school Mood Changes / Anger issues aggressed after graduating hs Felt abandoned emotionally by her mom Currently enrolled in junior college Average student Fear of withdrawing from college Torn between changing majors and continuing with college education Desires to have a better life plan for herself and her child Considered the idea of joining the military
Family of Origin (mom, step-dad, two brothers, and a son) Oldest sibling Distant relationship with mom Academic Currently attending community college Social life Dating son’s father Occasion fights and arguments Employment Currently working at fast food restaurant
Intake Assessment Lack of support system at home / career choice Emotional stress and depression Beck Depression Inventory (BDI-II) Minimal 0-13, Mild 14-19, moderate 20-28, and severe 29-63 Test-retest reliability Increased content validity The Substance Abuse Subtle Screening Inventory (SASSI-3)
Intake Assessment Lack of support system at home / school Emotional stress and depression from the strained relationship with her mom and step-dad Beck Depression Inventory (BDI-II) Mild level of depression; score of 16 The Substance Abuse Subtle Screening Inventory (SASSI-3) Low Probability on FVA, FVOD, SYM, OAT, SAT, DEF, SAM, FAM, and COR
Axis I – Clinical Disorders Diagnosed with depression Axis II – Personality Disorders / MR No Diagnosis (V71.09) Axis III – General Medical Conditions None reported Axis IV – Psychosocial / Environmental Problems Feels as if her mom sides with her step-dad, no supportive system within her family structure, relationship problems with boyfriend, at a cross road with career / college choice Axis V – Global Assessment of Functioning 61-70
Treatment Plan Monitor level of depression Continue counseling sessions with appointed counselor Continue medication Recommendations Encourage the client to continue her education and seek out a career advisor concerning her career choice. Seek counseling with her mom in order to build a support system with her and her step-dad.
Beck, A.T. (1996). Beck Depression Inventory II (BDI-II) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Miller, G.A. (1988, 1997). The Substance Abuse Subtle Screening Inventory (SASSI) Manual, Second Edition. Springville, IN: The SASSI Institute. Whiston, S. C. (2009). Principles and Applications of Assessment in Counseling, Third Edition. Cengage Learning.