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Aardvark Counseling Center
Aardvark Counseling Center
INTAKE EVALUATION
CONFIDENTIAL
Referral Source :
Ms. Example is 57 years old, married, White female referred to Aardvark Counseling
Center by Dr. Ima Smart, her family general practitioner, for psychological assessment and
therapy. The clients states that she was referred after she had an uncontrollable crying spell in
her physicians office and revealed thoughts of suicide to the physician.
Informants :
The client attended the session alone. However, records from a prior psychiatric
hospitalization were brought by the clients to the sessions and also reviewed for this report.
Presenting Problems :
The clients reports that she is depressed and presents with the following symptoms :
dysphoric mood, frequent crying, anhedonia, initial insomnia, overeating and weight gain,
lethargy, poor concentration, and infrequent passive suicidal ideation. She also complains of
increased social isolation and worry about the future. The client describes several physical
problems including chronic arthritis, headaches, and occasional dizziness. She also states that
she feel badly about herself and does not know why she is depressed.
Clinical Formulation
Ms. Example has suffered with bouts of depression for many years. Some episodes seem
related to situational stresses, whereas other seem unrelated and may have biological
component. Her positive family history of depression. Alcohol abuse and suicidal behavior
further indicates a biological basis. She also seems to have some difficulty with assertiveness
and appropriate expression of feelings. The current episode appears to be related to increased
conflict with her husband, the death of her pet, and illness in her son.
DSM IV Diagnostic Impressions
AXIS I : 296.33 Major Depressive Disorder, Recurrent, Severe Without Psychotic Features
(Provosional)
AXIS II : Deferred
AXIS III : Chronic arthiritis, headaches, occasional dizziness, lethargy
AXIS IV : Psychosocial stressors, unemployment, isolation, conflict with husband, death of pet,
son
diagnosed with serious illness
AXIS V : Current GAF : 55
Highest GAF past year : 75