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Biopsychosocial Report

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Date: 25th October 2023

Client Name: H.B
Referral Source: General Physician
DOB: 4th March 1978
Demographic. The client's name is H.B., a 45-year-old African-American woman. She is a
cisgender heterosexual who lives with her husband of 3 years. H.B. has two children, a daughter
(9 years) and a son (5 years old); they live with her at home. The client indicated that she is self-
employed and runs her interior design firm. H.B. reports that she has resided in the United States
since birth. Currently, she lives in Downtown Indianapolis—The client reported having three
siblings: two brothers and one sister. The client reports not having any grandchildren. She has
both parents, whom she rarely sees. H.B. reported her highest level of education being a Diploma
in Interior Design.
Physical health/limitations: The client stated that she has been looking for psychotherapy due
to the high levels of anxiety she deals with after she was recently involved in a car accident. She
reported having irregular sleeping patterns, poor sleep, waking up in the middle of the night, and
having frequent nightmares. The client also reported getting approximately 4-5 hours of
continuous sleep every night. She has also resorted to taking sleep supplements that aid in her
getting proper sleep. She also reported more signs, such as negative thoughts of getting into an
accident, excessive fear when she is on the road, feeling guilty, intrusive suicidal thoughts, and
also got into negative self-talk. The client further reported that her husband would take her to the
assessment, and she has stopped driving herself ever since the accident, which took place about
three months ago. She reported that the symptoms were not visible before the car accident, and
she has never had issues with sleep. The client reported drinking at least two glasses of wine
daily.
Name of the primary care Doctor: Doctor Klyne Stewart. The client is very aware of the
medical issues she is dealing with and how it continues to affect her day-to-day performance.
Prescriptions: Benzodiazepines and antidepressants. The client reported there are no over-the-
counter medications she uses.
Evaluation of their ADLs: The client reported being able to carry out her usual activities.
However, she needs help driving. The client reported being scared to drive as this triggered her
anxiety attack. Besides this, the client reported being able to carry out her daily activities.
Sensory Limitations: The client reported needing to wear spectacles as she is short-sighted. She
also reported difficulties seeing in low light, inhibiting her driving.
Abuse/Neglect: The client exhibited no signs of neglect or abuse. She reported that her family
members are always there for her whenever she needs them. The client reported getting a lot of
support from her husband, parents, and siblings during this time, and she has had to hire help for
her children when she is low.
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Psychological functioning: The client reported her most significant stressor now is her job and
finances. She reported that after getting into the accident, she had to spend a lot of time away
from work, which resulted in reduced sales, and her firm generally declined. The client reported
her husband has had to struggle with finances as her finances also contributed to the general
expenses of the house. The client reported her most significant accomplishment was her interior
design firm, which she has worked on for five years, to what it is today. The client reported her
greatest joy was her kids and the family around her, as they have been quite supportive.
Intelligence: The client reported that for her to remain sane, she tries to do some exercises at
home. She also draws and ensures to explore her creative side. Memory: The client reported not
being worried or concerned with memory loss as she does not feel like she is that old.
Social Functioning: The client reported having two friends she meets occasionally, mainly after
church. The client reported that her significant activities are her job, family, and ensuring she
does not do more things than she can handle. The client reported not wanting to participate in
more activities and is quite content with what happens in her daily life.
Lifestyle: The client reported that the most challenging part of her day is whenever she has to
close her eyes for a nap or to sleep. Also, she is pretty scared of being on the road and having to
drive anywhere.
Conclusion: The client is a 45-year-old African American, married, heterosexual woman who
lives in Indianapolis with her husband and their two children. The client reported symptoms after
a traumatizing car accident approximately two months ago. She has difficulty sleeping. The
client stated that she does not have any underlying mental conditions. The client does not have
any intention to cause herself harm and is very hopeful about the future.