History of Presenting Illness and Chief Complaint

Justin is a 23-year-old and identifies as Puerto Rican straight cisgender male. Justin was seen by the school's crisis team following a phone call from a classmate who was concerned. Justin had missed classes for a week, which is uncharacteristic of him.When the crisis team arrived to Justin's dorm room they found all the shades drawn and lights were off. Justin appeared disheveled. He was wearing a pair of sweatpants and a T-shirt that looked as though had been worn for several days in a row. Justin had slight body odor and his skin and hair appeared oily. He reported he has not left his room in the past week due to his fear of being watched.

Justin reported that he had been working on a mathematics problem that was considered an unsolvable for the past six months. However, a week ago he solved this math problem, and was now fearful that this unidentified individual was after him. He reported he was able to solve the math problem because an angel had come in spoken to him. Justin was now fearful that the government would know he solved this math problem and Wood incarcerate him for his knowledge.

Histories

Family History:Justin is the oldest of three and his family. He has two younger sisters, age 18 and age 16. He reported having a good relationship with his siblings, however they do not spend as much time together since he's moved to the Boston area.Justin reports having a very close relationship with his mother and father. His mother was a stay at home mom for most of his life and recently started working in a doctor's office as a receptionist. His father is a mechanic and has owned his own business for the past 18 years. Justin is the first individual and his family to attend college. Justin has minimal contact with his extended family due to them living in Puerto Rico. He notes visitation generally only happens once or twice a year.

Education/Work History:Justin graduated high school at 18 years old. He initially attended a community college for two years where he obtained an associate degree. He transferred to a state college and was studying mathematics. Justin received a full scholarship to the State University. And graduated top of his class. He was then recruited for a graduate program at MIT and offered a full scholarship.Justin has attended MIT for one year. He is also working at a community coffee shop to help offset living expenses.

Social/Peer: Justin has dated on and off over the last several years. However, he does not identify any of these relationships as serious. He has been with his current girlfriend for five months, and this is the most serious relationship he has been in thus far.Justin has a supportive peer network. He has five (5) reported close friends on campus that he usually engages with on a daily basis. They will often spend time with each other engaging in activities on campus, going out to the movies, or going out to eat. Justin has a few friends from home that he is still in contact with, but generally they only talk through snap.

Strengths:Justin is an intelligent and articulate individual. He is resilient and prior to this current episode is resourceful and insightful. He has the ability to develop and sustain peer relationships. He has a good and supportive relationship with his identified family. Justin has strong communication skills. He possesses skills to be successful academically as well as in employment. He can work independently as well as a member of a team.

Trauma History:No reported history of trauma

Mental Health History: No reported mental health history. No medical documentation provided regarding previous treatment.

Substance Use History: ETOH, age of 1^st use: 18, last use "three weeks ago"

Justin reports occasionally drinking a beer or two with his friends on the weekend.

Medical History:Justin has reportedly in good physical health. He is up-to-date on his physical as well as any immunizations. He has not sustained any head traumas and does not suffer from any chronic medical conditions. There has been no reported surgical history.

Family Medical/Mental Health/Substance Use History:

Justin's father has been diagnosed with high blood pressure and his mother battled breast cancer. There is no known family history of mental illness, however the family noted there was an uncle who was identified as crazy. When questioned further they stated they did not have much information as he was never around the family. There is no family history of substance use.

Mental Status

Justin speech was soft. The rate of speech vacillated between normal and rapid. When he spoke, he was often tangential and would get derailed on to various topics. When the crisis team attempted to clarify, he would become angry and shout "are you with them?" Justin was very difficult to engage in conversation. He kept asking questions regarding why the crisis team was there.

Justin reported his overall mood as fearful. His affect appeared anxious and suspicious. His eye contact was poor, and he often looked from person to person in an attempt to assess for any potential harm that may come to him. He denied hallucinations, visual and auditory, but at times appear to be responding to internal stimuli. He was observed putting his fingers in his ears and shaking his head periodically, even wn no one else was speaking.

Justin denied eating any food for the past several days and there was no food in the refrigerator or cabinets. He did report consuming large amounts of caffeine. Justin's table was littered with coffee cups and various paperwork. He reported interrupted sleep and sleep onset insomnia.Justin denied taking any medications. And denied using any substances. He reported the last time he had a drink of alcohol was over three weeks ago when he went out to dinner with friends.

Risk Assessment

Justin's level of risk is moderate-high. He denies any suicidal/homicidal ideation and he does not have a history of ideation or self-injury. However, he has been isolative and not eating. He appears to be responding to internal stimuli and is not engaging in his typical self-care and routines.

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Clinical Formulation

This is your clinical interpretation of what is happening with the client. This will include only relevant background information and symptoms that are related to your diagnosis. This is the justification of your diagnosis. DO NOT INCLUDE THE DIAGNOSIS HERE!

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Diagnostic Formulation You must reference the DSM-V

You must include a statement of demographics, the diagnosis, and the criteria needed to justify the diagnosis. Make sure you report enough symptoms to make the diagnosis! DO NOT INCLUDE INTERPRETATIONS OR JUSTIFICATIONS HERE.

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Treatment Plan

Client Goal (take a guess as to what the client would want their goal to be)

Clinical Goal (take the clients goal and write it in clinical terms)

Objective (measurable step to get to the objective - what will be different?)

Intervention (name one intervention and how you would use it to work toward the objective)