· Referral information: Client reported that she has been struggling with her mental health and symptoms have been worsening since last year. Being recommended by CMH to agency. Client said she wants to "Getting to what I used to be, being able to get to a functioning level, take care of my child and work". Specifically need therapy, case management.  · History of presenting problem(s):  · She reported that she sleeps all day, has difficulties getting out of bed, has low energy, low motivation and has been unable to attend work, has been hopelessness, worthlessness, isolating and not able to tend to her activities of daily living. Stated that she has been endorsing symptoms of depression for "quite a while" and the past several months things have been worsening. · She reported that she currently doesn't have any thoughts of hurting self however has a history of suicidal thoughts including attempts. Stated that she has had suicidality all throughout the Fall of 2019. She also has history of suicide attempts prior to the most recent attempt stating that in the past she "has many overdoses mostly on pills that were prescribed and Tylenol". She reported a history of self-harming thoughts and behaviors. Stated that in the summer and fall of 2019 she has cut self and prior to that she hasn't cut herself since her early 20s.  · Client works at a Senior day program in Ypsilanti and has housing at this time however is at risk of losing employment and housing due to her worsening symptoms and inability to care for herself.  · Bio-psycho-social-spiritual history: · Biological domain: Client is a 35years old female-single with two children. White. She reported that she was previously on the following: Paxil, Celexa, Lexapro however all have been discontinued and uncertain why.  · Psychological domain: Denied any auditory of visual hallucinations or paranoia. She reported that she currently doesn't have any thoughts of hurting self however has a history of suicidal thoughts including attempts. Stated that she has had suicidality all throughout the Fall of 2019 with an attempt in august. · Social domain: Born and raised in Dexter by both parents. Her parents are still together and alive. She has three siblings (two brothers and a sister) and client is the middle child. She stated that her siblings and her "get along but aren't super close". She reported a history of sexual assault.  She shares custody of her 4years old son with her ex. Her son has been staying mostly with his father due to her worsening depression. She stated that she hopes to get better soon so he can return to her home. She stated that when she spends time with her 4 years old son she feels "drained" after her son leaves.  She worked at the senior center after earned a Bachelors in Social Work at EMU. Is at risk of losing her employ.

1. · Referral information: Client reported that she has been
struggling with her mental health and symptoms have been
worsening since last year. Being recommended by CMH to
agency. Client said she wants to "Getting to what I used to be,
being able to get to a functioning level, take care of my child
and work". Specifically need therapy, case management.
· History of presenting problem(s):
· She reported that she sleeps all day, has difficulties getting
out of bed, has low energy, low motivation and has been unable
to attend work, has been hopelessness, worthlessness, isolating
and not able to tend to her activities of daily living. Stated that
she has been endorsing symptoms of depression for "quite a
while" and the past several months things have been worsening.
· She reported that she currently doesn't have any thoughts of
hurting self however has a history of suicidal thoughts including
attempts. Stated that she has had suicidality all throughout the
Fall of 2019. She also has history of suicide attempts prior to
the most recent attempt stating that in the past she "has many
overdoses mostly on pills that were prescribed and Tylenol".
She reported a history of self-harming thoughts and behaviors.
Stated that in the summer and fall of 2019 she has cut self and
prior to that she hasn't cut herself since her early 20s.
· Client works at a Senior day program in Ypsilanti and has
housing at this time however is at risk of losing employment
and housing due to her worsening symptoms and inability to
care for herself.
· Bio-psycho-social-spiritual history:
· Biological domain: Client is a 35years old female-single with
two children. White. She reported that she was previously on
the following: Paxil, Celexa, Lexapro however all have been
discontinued and uncertain why.
· Psychological domain: Denied any auditory of visual
hallucinations or paranoia. She reported that she currently

2. doesn't have any thoughts of hurting self however has a history
of suicidal thoughts including attempts. Stated that she has had
suicidality all throughout the Fall of 2019 with an attempt in
august.
· Social domain: Born and raised in Dexter by both parents. Her
parents are still together and alive. She has three siblings (two
brothers and a sister) and client is the middle child. She stated
that her siblings and her "get along but aren't super close". She
reported a history of sexual assault.
She shares custody of her 4years old son with her ex. Her son
has been staying mostly with his father due to her worsening
depression. She stated that she hopes to get better soon so he
can return to her home. She stated that when she spends time
with her 4 years old son she feels "drained" after her son
leaves. She worked at the senior center after earned a
Bachelors in Social Work at EMU. Is at risk of losing her
employment due to her worsening MH symptoms. Currently
lives alone but sometimes has her son. She also has a 13 years
old girl lives with her parents as she gave custody to her parents
when she was pregnant with her 4 years old son and was
struggling. She lives close by and has a good relationship with
the girl. Two kids have different fathers. She denied having any
marriages. Denied any homelessness.
· Spiritual domain: She likes to travel, spend time with kids,
read, spend time with friends and family, swim as her leisure
space. She is “spiritual sometimes", her kids are her protective
factors.
· Psychiatric history:
· She was psychiatrically hospitalized three times and attended
partial-hospitalization twice all in the past fall of 2019. Denied
any changes to her appetite.
· She was hospitalized in 2007 for a suicide attempt via
overdose. Client reported that she has a history of outpatient
mental health treatment.
She also reported "some anxiety" with a history of panic attacks
however "not very often but has them occasionally". She

3. reported endorsing a panic attack: "crying, trouble breathing,
can’t get thoughts in order, my heart is racing". Last time she
endorsed a panic attack was about a month ago while she was at
work.
· She reported that she has been diagnosed with Depression,
Bipolar disorder, borderline personality, and anxiety.
· Current psychiatric presentation:
· She reported that she hasn’t been to see a psychiatrist in a
long time.
· Reported that her meds have been changed a few times in the
fall however since September has been on the same meds.
· She is on the following medications: Effexor 225mg once per
day, Abilify 5mg once per day.
· She reported that she discontinued the Abilify on her own in
October however alerted her Primary Care Physician.
· Stated that the Abilify "made me very agitation" and she isn’t
sure why she was placed on Abilify to begin with.
· PCP has been prescribing her meds however she feels she
needs a psychiatrist and additional support through a mental
health provider to prevent her from re-hospitalization.
· Identification of any effects of racism, discrimination, sexism,
power, privilege, and oppression on your client’s concerns or
history
No racism, no discrimination, no sexism, no legal issues.
· Clinical case formulation summary:
Client is 35 years old white female-single with two children.
She has been struggling with her mental health and symptoms
have been worsening since last year. She reported that she has
been diagnosed with Depression, Bipolar disorder, borderline
personality, and anxiety.
She sleeps all day, has difficulties getting out of bed, has low
energy, low motivation, anhedonia and has been unable to
attend work, has been endorsing hopelessness, worthlessness,
isolating and not able to tend to her activities of daily living-
showering, cleaning, cooking. Stated that she has been

4. endorsing symptoms of depression for quite a while and the past
several months things have been worsening. She was
psychiatrically hospitalized three times and attended partial-
hospitalization twice all in the fall 2019.
She endorsed a panic attack about a month ago while she was at
work. She hasn’t been to see a psychiatrist in a long time.
Reported that her meds have been changed a few times in the
fall however since September has been on the same meds.
Primary Care Physician has been prescribing her meds however
she feels she needs a psychiatrist and additional support through
a mental health provider to prevent her from re-hospitalization.
She works at a Senior day program in Ypsilanti and has housing
at this time however is at risk of losing employment and
housing due to her worsening symptoms and inability to care for
herself. She has her own vehicle and has a driver’s license. And
she considers herself would be a good mother, would be able to
hold down a job, go out with friends and family. Strengths she
has is as a social work graduate, she has higher adaptability of
treatment plans.
As well as she says she is a good mother when she is doing
well, she is compassionate opened minded person. She has her
mother as her strong back up and her kids are her protective
factors. The challenge facing is her panic attack, depression and
anxiety is serious and her history of suicidal thoughts her recent
attempts. Could be a tough barrier considering various
elements.