Clinical Assessment and Client History (PLEASE TYPE OR PRINT LEGIBLY) Type of Report: Initial Client Name: DAVID CRUZ Date of Interview: __8/17/2023_______________ Clinician Completing Interview: ____MSW STUDENT______________ Date of Review: __8/17/2024_______________ Referral Source: PCP Psychiatrist Case Manager XX Self Other __________________________________ Demographic Information: Biological Sex: XX Male Female ______________ Current Gender Identity: XX Male Female Trans____________ ______________ DOB: __2/22/99_______ Age: __24 yrs old_________ Birthplace: _Phoenix, AZ______________________________ Housing: Homeless X Lives alone Lives with other(s) _________________________________ Presenting Problem(s): Ct self-referred for psychotherapy due to multiple stressors and mood issues. Ct reported a recent break up with his boyfriend Mike on 8/1/23. Ct stated his boyfriend broke up with him and moved back to Florida to be with his ex- boyfriend. Ct stated he attempted to propose to his boyfriend Mike on 7/31/23 because they had been dating for 2 years but he said no. Ct stated Mike ended the relationship the next day on that day on 8/1/23 and moved of their apartment on 8/5/23. Ct recalled Mike telling him, "You smother me and you are too needy". Due to his Ex-boyfriend Mike moving out of the apartment they have shared since 2/1/22, Ct is worried he will not be able to afford the rent. Ct stated "This entire experience has been devastating and I am crushed by the break up and I have to move out of the apartment I love". Ct reported no previous mental health issues but he is currently feeling daily anxiety, agitation and worry which affects his ability to sleep. Ct stated he is not able to fall asleep or stay asleep several times a week since the relationship ended on 8/1/23. Prior to 8/1/23 he was able to sleep 7-8 hours per night and felt rested. Ct stated he has daily racing thoughts about is ex-boyfriend Mike and is having difficulty concentrating on his work or daily activities including not showering every day and not cleaning his apartment. Ct stated, "I don't want to do anything but play video games all day so I am not doing my dishes or laundry which is different for me because I like a clean apartment". Ct did state even though he is needing to move at the end of October 2023 he is keeping up with his budget and financial responsibilities. Ct stated he will get up and complete his work remotely since he works from home but is not finishing his work on time or thoroughly which is also different for him since he always did "great work and completed work on time and efficiently". Ct stated due to missing a crucial deadline on a project that was due on 8/8/23 he was put on a Performance Improvement Plan (PIP) on 8/10/23. Ct recalled no history of work difficulties until recently. Ct stated, "I was looking forward to the future but I feels confused as to what the future will look like without Mike. Ct denies current and history of DTS, DTO and substance use. History of Presenting Problem(s): Stressors or precipitating factors leading to need for services: Ct recalled 2 other relationships ending "badly". Ct stated he dated 2 other men who also broke up with him. He dated Brian in 2020 and Lou in 2019. Ct dated Brian while he was in college, "I thought everything was fine but then it ended". Ct stated he dated Lou in high school, "I knew that relationship was going to end, I was not surprised". Ct stated his parents, Jeff & Linda divorced when client was 10 years old which "was awful but my parents were not good together they fought all the time". Ct denied any abuse or neglect but felt the fighting was difficult to witness as a child. Ct expressed, "Growing up I looked forward to having a healthy relationship because I grew up watching my parents fight all the time". Mother remarried Step-father Guy when client was 15 years old and client lived fulltime with mom and step-father until he went to college. Father has not remarried but has had several girlfriends. Ct did not provide any further information given at this time. Ct declined to include any further details regarding his childhood.

Client Name: __David Cruz 2 Frequency/Intensity/Duration/Cycling of Symptoms: Ct stated he experiences moderate daily anxiety, agitation, worry, racing thoughts, and lack of concentration since August 1, 2023. Onset of Presenting Problem: Month August Year 2023 Was there a clear time when symptoms worsened and/or Event(s)/Situation(s) that lead to symptom(s) worsening? Ct stated, "Everything went to hell when Mike broke up with me on August 1, 2023". Ct feels the need to move out of his apartment was another event that contributes to his symptoms and issues. Severity Assessment: (If yes, elaborate) Suicidal Current X No Yes _________________________________________ Suicidal History X No Yes _________________________________________ Psychotic Current X No Yes _________________________________________ Psychotic History X No Yes _________________________________________ Homicidal Current X No Yes _________________________________________ Homicidal History X No Yes _________________________________________ Violent Current X No Yes _________________________________________ Violent History X No Yes _________________________________________ Neurological Current X No Yes _________________________________________ Neurological History X No Yes _________________________________________ Mental Status Exam: WNL (Within Normal Limit) Elaborate on mental status categories Moderate or Severe General Appearance Appropriate Disheveled Emaciated Obese Poor Hygiene Clothing was appropriate but were wrinkled and appeared to be soiled, ct's hair appeared messy Dress Appropriate Eccentric Seductive Bizarre Severity Level = Mild Moderate Severe Memory Intact Poor Remote Poor Recent Not Assessed Severity Level = Mild Moderate Severe Attention/Concentration Good Distractible Variable Not Assessed Severity Level = Mild Moderate Severe Motor Activity Unremarkable Agitation Retardation Posturing Tics Repetitive Action Tremors Unusual Gait Not Assessed Severity Level = Mild Moderate Severe Mood Euthymic Depressed Dysphoria Anxious Angry Irritable Euphoria Grandiose Not Assessed Severity Level = Mild Moderate Severe Affect Appropriate Inappropriate Labile Constricted Blunted Flat Not Assessed Severity Level = Mild Moderate Severe Speech Appropriate Hesitant Pressured Slurred Soft Stuttering Mute Verbose Not Assessed Severity Level = Mild Moderate Severe Thought Content Appropriate Preoccupied Obsessive Delusion ______________________ (Type) Not Assessed Severity Level = Mild Moderate Severe Insight Good Fair Poor Not Assessed Severity Level = Mild Moderate Severe Judgment Good Fair Poor Not Assessed Severity Level = Mild Moderate Severe Perception Unremarkable Auditory Hallucination Visual Hallucination Olfactory Hallucination Tactile Hallucination Gustatory Hallucination Not Assessed Severity Level = Mild Moderate Severe

Client Name: __David Cruz 3 Flow of Thought Unremarkable Blocking Circumstantial Flight of Ideas Loose Association Perseveration Tangential Not Assessed Severity Level = Mild Moderate Severe Interview Behavior Appropriate Aggressive Angry Apathetic Child-like Argumentative Demanding Dramatic Evasive Hostile Irritable Passive Manipulative Withdrawn Uncooperative Not Assessed Severity Level = Mild Moderate Severe Is the client able to manage activities of daily living? Yes X No If No, describe: Ct is not showering every day, he is not doing his dishes or laundry Estimated level of intelligence: Average Orientation: ___XX___ Time ___XX___ Place __XX____ Person Level of insight: ____ Complete denial ____ Blames others ____ Intellectual insight, but few changes likely ____ Emotional insight, understanding, change can occur __X__ Slight awareness __X_ Blames self Family Information Living? Relationship Name Age Yes No Mother Linda Cruz _____________________ __48____ _X__ _____ Father Jeff Cruz_______________________ __48 _ _X___ _____ Spouse _________________________________ ________ _____ _____ Children _________________________________ ________ _____ _____ Other _Step-father Guy__________________ __50____ _____ _____ Other _________________________________ ________ _____ _____ Other _________________________________ ________ _____ _____ Marital status (more than one answer may apply) _X___Single ____ Married ____ Living together ____ Separated ____ Divorced ____ Widowed Assessment of current relationship (if applicable): ____ Good ____Fair __X_Poor Ct ex-boyfriend recently ended the relationship in August 1, 2023 per Ct Parental Information ____ Parents married __X__ Mother remarried: Number of times: _1___ ____ Parents Never Married _X _ Parents Divorced __X__ Father remarried: Number of times: __0__ Father has not remarried but has had several girlfriends, no other information given at this time

Client Name: __David Cruz 4 Development Are there special, unusual, or traumatic circumstances that affected your development? __X__ Yes ____ No If Yes, describe Ct stated his parents, Jeff & Linda divorced when client was 10 years old which "was awful but my parents were not good together they fought all the time". Ct denied any abuse or neglect but felt the fighting was difficult to witness as a child. Ct expressed, "Growing up I looked forward to having a healthy relationship because I grew up watching my parents fight all the time". Ct declined to include any further details regarding his childhood. Mother remarried Step-father Guy when client was 15 years old and client lived fulltime with mom and step-father until he went to college. Father has not remarried but has had several girlfriends. Ct did not provide any further information given at this time. Has there been a history of child abuse? _X___ Yes ____ No If Yes, which type(s)? ____ Sexual _____ Physical ___X__ Verbal ___X__ Emotional If Yes, the abuse was as a ____ Victim ____ Perpetrator Other childhood issues: ____ Neglect ____ Inadequate nutrition ____ Other _________________________________ Comments regarding childhood development: Ct stated, "My childhood was not bad but it was hard when my parents were together and they were fighting". Social Relationships Check how client generally gets along with other people: (check all that apply) __X_ Affectionate ____ Aggressive ____ Avoidant ____ Fight/argue often ____Follower __X_ Friendly ____ Leader ____ Outgoing __X_ Shy/withdrawn ____ Submissive ____ Other ____________________________________ Sexual orientation: _Gay Male____________ Comments: ______________________________________________________ Sexual dysfunctions? ____ Yes __X__ No If Yes, describe: _____________________________________________ Please describe Interpersonal Relationship Information including Marital Issues, Intimacy Issues, Bullying etc: Ct reported recent break up in September 1, 2023. Ct was attempting to propose to Mike but he broke off the relationship to move back to Florida with his ex-boyfriend. Ct recalled Mike telling him, "You smother me and you are too needy". Ct indicated when he plays video games he interaction with his friends, friend names were not reported at this time Cultural/Ethnic Cultural/Ethnic Affiliation(s): Asian-American, gay male, ct stated he feels video gaming is part of his culture and enjoys interacting with friends while playing Zelda and Minecraft Spiritual Affiliation: Ct denied current and history ___________________ Practicing? Yes X No

Client Name: __David Cruz 5 Legal Current Status Is client involved in any active cases? If so, describe and indicate court and hearing/trial dates and charges. ____Traffic: __________________________________________________________________________________________ ____Civil: ____________________________________________________________________________________________ ____Criminal: _________________________________________________________________________________________ ___XX__No active cases Is client currently on parole or probation? ____ Yes _XX___ No History Traffic Violations ____Yes ___XX_No DUI or related: ____Yes __XX__No Criminal involvement: ____ Yes __XX__No Civil involvement: ____Yes ___XX_ No If Yes to any of the above, describe below: NONE REPORTED AT THIS TIME Charges Date City/State Disposition ____________________ ___________________ __________________________ __________________________________ ____________________ ___________________ __________________________ __________________________________ Describe incidents, criminal charges, and any other information relating to Legal Issues: NONE REPOERTED AT THIS TIME ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Does the client have a living will? ______Yes ___ XX_No Power of attorney? ______Yes ____XX_No Who:________________________________________ Medical power of attorney? ______Yes ____XX_No Who:________________________________________ Education Fill in all that apply: Years of education ___16___ Currently enrolled in school? ____Yes _XX___No __XX High school grad/GED ____ Vocational Number of years: ____ Graduated: ____ Yes ____ No Major ________________________ __XX College Number of years: _4___ Graduated: ___XX_ Yes ____ No Major: Computer Science, ASU, 2020 ____ Graduate Number of years: ____ Graduated: ____ Yes ____ No Major ________________________ Other training: ________________________________________________________________________________________ Special circumstances (learning disabilities, gifted, etc.) _______________________________________________________ Employment Begin with most recent job and list history: Employer Dates Title Reason left the job How often missed work? Tech, Inc June 2021 to Present Data Analyst Ct reporting not completing work Ct reported being put on a Performance Improvement Plan (PIP) on August 10, 2023 Currently: __X__FT ____PT ____Temp ____Laid off ____ Disabled ____ Retired ____ SSI/D ____ Student ____ Other ____________________________________________ Military

Client Name: __David Cruz 6 Military experience? ____ Yes _XX___ No If yes what branch & rank: ___________________________________ Combat deployment experience? ____ Yes ___XX_ No If yes describe circumstances: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Medical/Physical Health Pregnant? Yes XX No Unknown Allergies: _None reported at this time Primary Care Physician: Dr Jane Jones______________________________________ Current Medical Diseases or Disorders Diagnosed (specify age of onset, if chronic, etc.): NONE REPORTED AT THIS TIME Current medical treatment/medications, side effects and target symptoms: NONE REPORTED AT THIS TIME History of head trauma (include description of each, i.e., treatment, loss of consciousness, seizures, rehabilitation, dates and lengths and facilities): NONE REPORTED AT THIS TIME Substance Use History Type of Substance Method of Use Frequency Date Started Date Last Used None reported at this time _____________ _______________ ___________ _____________ ________________________ _____________ _______________ ___________ _____________ ________________________ _____________ _______________ ___________ _____________ ________________________ _____________ _______________ ___________ _____________ Reason(s) for use: ____ Addicted ____ Build confidence ____ Escape ____ Self-medication __ Socialization ____Taste ____ Other _________________________________________

Client Name: __David Cruz 7 Mental Health and/or Substance Use Treatment History Client's Treatment Information (Current and Past) Type of Treatment & Name of Clinical Provider When Where CT DENIED A HISTORY OF MH/SUD TREATMENT HISTORY __________________________________ ______________ _____________________________________ ___________________________________ ______________ _____________________________________ ___________________________________ ______________ _____________________________________ ___________________________________ ______________ _____________________________________ ___________________________________ ______________ _____________________________________ ___________________________________ ______________ _____________________________________ Current Psychiatrist/Mental Health Provider who is prescribing psychotropic/mental health medication(s) Name, Credential and Agency/Facility Name: NONE REPORTED AT THIS TIME Current Psychotropic/Mental Health Medication, Side Effects, Target Symptoms: NONE REPORTED AT THIS TIME Current Mental Health Symptoms: Ct stated he experiences moderate daily anxiety, agitation, worry, racing thoughts, and lack of concentration since August 1, 2023. Coping Skills List of ALL Adaptive and Maladaptive Coping Skills: Adaptive coping: Video games and interaction with his friends online, friend names were not reported at this time; ct has current health insurance United Healthcare; ct's cat is also supportive per ct Maladaptive: Ct reported not showering regularly, ct feels his daily racing thoughts about ex-boyfriend is not helpful, ct reported playing video games for too long at time, up to 10 hours/day when not at work Support System (Include all supports from an Ecological Perspective) Friends he interacts with when he plays video games online, ct reported he will reach out to his father weekly, ct has support from his supervisor and has reached out when he is needing a break at work, ct has current health insurance United Healthcare, ct feels his cat is also part of his support system

Client Name: __David Cruz 8 DSM 5-TR Diagnosis (List ALL Diagnoses, use correct number(s), specifier(s) and descriptor(s)s to describe current situation - please use bullet points to include all criteria/symptoms that justify the diagnosis) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Current Treatment Recommendations for EACH Presenting Problem (Include justification and reasoning behind recommendation you may use the Morrison book but please explore other resources as well from other classes such as SWG 510, 511 (Hepworth Book) & other 600 level classes)

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