PHYSICAL AND BEHAVIORAL OBSERVATION

Aaron Decena is a young boy with petite body and dark complexion. He
stands about 5 feet 7 inches tall, with a short black, straight hair. During the
sessions he wore black shirt and shorts. On an initial glance, he looks very timid but
he responded very well.
During the interview, he spoke in a very soft voice. He always has
handkerchief in his hand and used it to cover his mouth or wipe his face. He seems
very anxious in talking about his parents. He cannot maintain eye contact also,
when asked about the incident he did not open up readily. He said that he does not
want to remember anymore the death of his parents and talking about it brings
back a bitter memory that is why he is not comfortable in telling us about it.
To get some further information we asked him specific questions that he
answered directly. After talking about the incident, he told us about all the changes
that occurred in their lives and how they cope up with this event. When asked about
his relationship with his girlfriend his face suddenly lightened up and he smiled and
laughed occasionally.

TEST ADMINISTERED
Hamilton Depression Rating Scale (HAM-D) , Hamilton Anxiety Scale (HAM-A),
Major (ICD-10) Depression Inventory and Generalized Anxiety Disorder 7-item (GAD7) scale. These tests were administered on December 29, 2014. Hopkins Symptoms
Checklist, Harvard T Scale and Kinetic Family Drawing were administered on
January 18, 2015.

SUMMARY FORMULATIONS

Aaron Decena is a person who suffers from mild anxiety and depression after
he experienced two significant traumatic events. In effect, he became rebellious,
introvert and has low self-esteem. Because of these, he thinks of himself as weak
thus, he is not comfortable in talking about those incidents anymore. He also avoids
engaging or participating significant event.