Client Assessment Summary

Yesenia Watt

RECTH 3360

April 11, 2022

 Client Assessment Summary

Demographics:

Name: Aspen Richards

Age: 17

Gender: Female

Diagnosis: Generalized Anxiety Disorder with Major Depressive Disorder

Client Description:

Client is a 17, caucasian, female who was admitted to Copper Hills Youth Center on October

17, 2021. Client was admitted for Generalized Anxiety Disorder. She is having a hard time

concentrating, constantly irritable, experiencing shortness of breath, restlessness, and nausea.

Prior to admission, she fell unconscious in school after experiencing a severe panic attack in

class. This shocked her mother and was brought in to Copper Hills Youth Center.

Client has been using Escitalopram (Lexapro) and Duloxetine (Cymbalta) and states that she

experiences drowsiness or fatigue, and often feels aches in her muscles and joints.

Family or Patient Reports:

The mother of the patient has described the client as a good student and active in her social

groups. She does state that Richards gets irritable at home and that they get into at least three

fights a week. Siblings are moved out of the house, but client states that when they come to

visit, client feels left out and like she is missing information from her sister’s lives. Client states
that she is only close with her father but he is always out on business trips. It is also reported

that her anxiety is typically triggered through academic defeat and stress with social status.

Assessment Information:

Functional Abilities:

Social Functioning: Client was able to maintain conversation throughout the interview

without assistance. Actively involved with social groups at school, has friends in class and talks

to others on the swim team. Client does experience anxiety and states that she often compares

herself to the other girls on the swim team.

Physical Functioning: Client was physically able to participate in the interview without

any assistance. Active on the swim team and likes to workout in her spare time. Does

experience aches in muscles and joints and fatigues from medication.

Emotional Functioning: Client was able to relate information about emotional functioning

without assistance. Client does feel left out often in family dynamics and will get into fights often

with her mother.

Cognitive Functioning: Client shows cognitive functioning and understanding throughout

the interview without assistance.

Spiritual Functioning: Client states that she does not have any spiritual connectedness

but does try to meditate instead.

Leisure Functioning

Leisure abilities: Client is physically active and would prefer to be introduced to

more physically demanding activities.

 Leisure barriers: When something does not work out in the client’s favor, she

tends to give up easily.

Leisure behaviors/Participation patterns: Client will actively participate in

activities. However, if she loses motivation, will need encouragement.

Leisure attitudes: Client is interested in recreational therapy but will need help

and guidance through episodes with little-to- no motivation.

Client Interests:

Client’s interests include meditation, swimming, going to the gym and writing activities,

specifically poetry.

Client Strengths:

Client’s strengths include being physically active and socially active. She has stated that she

likes group recreation activities but prefers her leisure activities to be more separated from

others.

Client Areas of Concern:

Client struggles with comparing herself to others and seeing her own worth. She also feels like

she does not “fit in” in any part of her life (Family dynamics, school, sports team, etc.). Client

also loses motivation after any kind of defeat (Academic, social dynamic, and sport team).

Client Expectations:

Client wants to stop going to treatment and wants to regain control of her life. She wants to stop

fighting with her mom and wants to not feel the need to compare herself to her peers.

Precautions/Considerations:
Client struggles with physical side effects of her medication (Aches and pains in her muscles

and joints). No motivation after defeat.

Client Outcomes:

By discharge, the client will have an emotion regulation exercise to use when experiencing

defeat. Client will also have a healthy conversation with their mother about how she feels when

they fight.

Signature: Y. Watt, RT Student

Date: April 10, 2022