Client Intake Information Sheet Summary: Evaluator: Dr. Perkins Client Information: Name: Last Irving Marital Status: Single Age: 19 Summary: Current Complaint First Staniel Occupation: Tennis Pro Staniel was referred for an evaluation regarding depression by his family physician, Dr. Larned (contact information on file.) Staniel is a 19-yeard old male. He presented as somewhat shy and withdrawn during the interview. He appears to have been very open and honest during the interview and was willing to discuss all of his experiences. He reported that many members of his family saw therapists and psychiatrists. He reported he had always had "anxiety," but this was his first time visiting a mental health professional. Staniel stated that the problems started "four months ago" when he broke up with his girlfriend. He said they were "very much in love" but separated because she moved to Tampa Bay, Florida in order to start a "dream job." They talked at first, but eventually "it became too hard for her" to be in touch over such distance and "she felt forced to break it off." He said that since then he has been "heartbroken." He reported that he has been losing a significant amount of sleep over the last two months or so. He said he has lost weight, he has trouble motivating himself, and has trouble concentrating. He explained that his symptoms primarily come from "thinking about her all the time." Staniel went on at length about his ex-girlfriend, describing her, the things they used to do together, the plans he had for their future. He very strongly believes that they are "soulmates" and that she "has never felt the same way for someone else before" and neither has he. At some point before their relationship ended, he stated that she suggested that he come with her to Florida, but he said no. He said he is "wracked with regret" over his decision not to go, and thinks that is the point that he "hurt her so bad" that she had no choice but to end the relationship. He says thinking about her, and his future without him, gives him "tremendous anxiety." He repeated that he thinks "constantly" about her, to the point that he loses sleep, forgets to eat, and makes "dumb mistakes at work" When he is feeling anxious about her, about how he might have messed up, he will write her a letter or a text or an email to make himself feel better. He also said he will work on "his plan" to prove to her that he loves her too. When asked for details about his plan he said "it's the only thing that makes me feel less anxious now." He pulled out a map of the United States while discussing the "great romances" of a number of young adult novels. The plot of "Twilight" was especially of interest, and he compared himself to someone named "Edward" and her to someone named "Bella" On the map of the United States he showed where had plotted a walking course from Tucson, Arizona to Tampa Bay, Florida. The initial map was quite rough, but he went on at length about the different trails he could take. He stated that, once he walks all that way she will really believe that he is ready to be with her. Treatment History Currently receiving psychiatric services, professional counseling, or psychotherapy elsewhere? ( ) yes no Have you had previous psychotherapy? ( ) yes ( no Are you currently taking prescribed psychiatric medication (antidepressants or others)? ( ) yes If yes, please list: Health and Social Information Do you currently have a primary physician? Yes ( ) no Who is it? Dr. Greg Larned Are you currently seeing more than one medical health specialist? ( ) yes no When was your last physical? Last year Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.: Migraines Are you currently on medication manage a physical health concern? If yes, please list: Lifestyle Are you having any problems with your sleep habits? yes ( ) no Is yes, check where applicable: A) Sleeping too little ( ) Sleeping too much ( ) Poor quality sleep ( ) Disturbing dreams ( ) other How many times per week do you exercise? Daily Approximately how long each time? 3 hours (I am a tennis instructor) Are you having any difficulty with appetite or eating habits? no ( ) yes If yes, check where applicable: ( ) Eating less ( ) Eating more ( ) Bingeing ( ) Restricting no ( ) yes Have you experienced significant weight change in the last 2 months? :):):) Do Do you regularly use alcohol? ) no ( ) yes In a typical month, how often do you have 4 or more drinks in a 24 hour period? How often do you engage recreational drug use? ( ) daily ( ) weekly ( ) monthly ( ) rarely ) never Do you smoke cigarettes or use other tobacco products? ( ) yes (ho Are you currently in a romantic relationship? Ano Ayes If yes, how long have you been in this relationship? Complicated, on and off for three years On a scale of 1-10 (10 being the highest quality), how would you rate your current relationship? 5 In the last year, have you experienced any significant life changes or stressors? If yes, please explain: Symptoms Have you ever experienced any of the following? Dramatic mood swings Yes No Rapid speech Yes No Extreme anxiety Panic attacks No Phobias Sleep disturbances Hallucinations Unexplained losses of time Unexplained memory lapses Alcohol/substance abuse Frequent body complaints Yes/No Yes Yes No Yes No Yes No Yes Yes/No 2 2 2 2 0 0 9 997 2 2 Yes No Yes/No Yes/No Yes No Eating disorder Body image problems Repetitive thoughts (e.g. obsessions) Yes Repetitive behaviors (e.g. frequent checking, hand washing Yes/No Homicidal thoughts Yes/No Suicidal attempts Yes/No If yes, when? OCCUPATIONAL INFORMATION Are you currently employed? d?XXX), ) no ( ) yes If yes, who is your currently employer/position? Greater Desert Tennis Club If yes, are you happy with your current position? Yes Please list any work-related stressors, if any None FAMILY MENTAL HEALTH HISTORY Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following? (circle any that apply and list family member, e.g. sibling parent, uncle, etc.) Difficulty Depression Bipolar disorder Anxiety disorder Panic attacks Yes/No Yes No Yes Yes/No No Yes/No 0 Family member Mom, Dad, Brother Mom, Dad, Brother Mom, Dad, Brother Schizophrenia Alcohol/substance abuse Eating disorders Learning disabilities Trauma history Suicide attempts Chronic illness Yes No Great great grandpa Yes No Yes/No Yes/No Yes/No Yes No Yes No OTHER INFORMATION What do you consider to be your strengths? I am a hopeless romantic.