Evaluate pharmacological options based on the mental health needs of a client/patient. What is the patient's presenting problem and diagnosis based on your intake session with the patient? Recommend a medication and provide support for use based on the mental health needs of a client/patient. What are the treatment plan goals set by the patient and counselor at the intake session? Download the template for a treatment plan from the Your Desk multimedia presentation. Recommend a non-medical intervention and provide support for use based on the mental health needs of a client/patient. What are the acceptable treatment options available based on your diagnosis? Justify selection of either pharmacological or non-pharmacological intervention based on the mental health needs of a client/patient. Provide a pharmacological medication recommendation or a non-pharmacological recommendation, along with a reason for your selection and support for its use. Present which viewpoint you most align with. Support your selection with cited literature and studies. Write clearly with good organization and correct spelling, grammar, and syntax.

Marital Status: Separated

Referred by (if any)? Referred to treatment by my primary care doctor, Dr. Smith.

Current Employment Status: Part time as a dog groomer.

History

Have you previously received any type of behavioral health services (psychotherapy, psychiatric services, etc)? Yes, I was hospitalized when I was 17 for a suicide attempt and followed up with counseling services at a New Day counseling practice. Attended counseling for about 2 months.

Are you currently taking any prescription medication: Yes, thyroid medication. I take Levothyroxine 25mcg 1 x day.

Have you ever been prescribed any psychiatric medication? Yes, I was given medication after my hospitalization, at discharge- an antidepressant? Did not take it.

General Physical and Mental Health Information

1. How would you rate your current physical health? (Poor, Fair, Good, Very Good?) At the moment, fair. I am tired a lot and have low energy.
2. How would you rate your current sleep habits? (Poor, Fair, Good, Very Good?) Poor. I tend to sleep 10-11 hours a day. Have trouble staying asleep and wake up a lot.
3. Do you exercise? If so, how many days a week? No.
4. How is your appetite? Are you experiencing any eating problems? I have had poor appetite the past several months. Usually eat one meal a day.
5. Are you currently feeling down, depressed or hopeless? Down yes. Not hopeless. If so, for how long? Several months.
6. Are you currently experiencing any anxiety, panic attacks or have any phobias? No
7. Are you currently experiencing any chronic pain? Lower back pain
8. How often do you drink alcohol? Several times a week How many alcoholic beverages do you have on a day when you are drinking? 3-4 glasses of wine
9. Do you engage in recreational drug use? No If so, how often? N/A
10. Have you had any significant life changes or life stressors recently? Yes. I am recently separated from my husband of 4 years. He wants me to seek treatment for depression. I also have family stressors as my mother is currently receiving treatment for breast cancer and myself and my older sister are her main caregivers/support system.

AlcoholismYesFather

Drug AbuseNoDepressionYesFather, Maternal Grandmother

AnxietyYesMother, Sister

Panic AttacksNo

Obsessive Compulsive DisorderNo

Post Traumatic Stress Disorder No

Bipolar DisorderNo

Eating DisorderNo

SchizophreniaNo

Suicide AttemptsYesMyself

Psychiatric HospitalizationYesMyself