Aardvark Counseling Center

291 Anteater Road

Colorado Springs, CO 80933

INTAKE EVALUATION
CONFIDENTIAL

Name : Evelyn Example Examiner : Sue Student

Gander : Female Examination Date : 9/7/97
DOB : 2/22/40 Employment Status : Unemployed
Age : 57 Marital Status : Married
Education : High School

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.

History of Presenting Problems :

The clients reports that she first experienced symptoms of depressions in April 1990.
She relates that at that time she and her husband moved from California to Colorado because
of business opportunities for her husband. She stated that she missed her children who live
near her in California and became increasingly isolated. She noted that her depressive
symptoms worsened over the next year, and in May 1991, she was hospitalized for 5 days at St.
Lukes Hospital due to severe depression and suicidal thought. She reportedly was prescribed
Paxil (60mg daily), but notes that she stopped taking the medication soon after discharge due
to side effect. She stated that in June 1991 she received follow up individual therapy with local
psychologist, Dr. Heather Jones. The clients related that her symptoms slowly remitted and she
ended therapy in September 1991. That treatment is described by the clients as cognitive
behavioral in nature. She reports that for the following several years she experienced few
symptoms until about age 53 (1993). Since that time, the clients reports chronic and debilitating
depressive episodes lasting several months at a time. These episode include all symptoms
noted previously. The currents episode reportedly began in January 1997 after conflict with her
husband greatly intensified. She also relates that at that time her cat died and her son was
diagnosed with bone cancer. She relates that she has not sought treatment since her brief
therapy in 1991. The client denies ever experiencing symptoms of mania.

Other Relevant History :

Ms. Example grew up in Sunnyside, California, a rural farm town. She is unaware of any
complications during her birth or postnatal difficulties. All developmental milestones were
reached without delay. She described a happy childhood working on the family farm. She is the
youngest in a sibling of three. She states that she maintains regular contact with her two sisters
who both live in California, but does not feel to close either. She has two children who live
together in California. She states that she is very close her daughter (age 34), son (age 31), and
two grandchildren, but is unable to see them very often due to geographical separation. She
states I miss them all dearly. According to the client, her son was diagnosed with bone cancer
in January 1997, and has relatively poor prognosis for recovery. She states Hes doomed. Her
father reportedly died in 1986 and her mother has lived with the clients children since that
time. The clients states that she is worried about her mother because she has not adjusted well
to the death of her husband. The client reports that she worked for many years as a home
health aide, but that in February 1993 she lost her job when the agency went out of business
and has not worked since then, The client notes that both of her parents have a history of
depression, and her mother was briefly hospitalized in 1988 following a suicide attempt. She
also suggest that her father had an undiagnosed alcohol problem. She states that she never got
along with her father and did not like that he spent the family money on alcohol. Her
relationship with her mother is generally characterized as warm and supportive, although not
as close as when the client lived in California.
Ms. Example reports that she met her future husband at age 17, and married at age 18
(1958). Her husband reportedly work as manager of a local restaurant and bar. The client
describes a stormy an conflictual relationship with her husband, with reportedly infidelity on his
part. She states that initially the relationship was satisfactory, but that for the past 4 years they
have frequently argued about diverse topics such as finances, children and leisure activities.
The clients reports that her husband frequently gambles away his earnings, stays out overnight
on a regular basis, and maintains romantic relationship with several females bartender at his
restaurant. She states he cheating is so obvious it makes me sick. The client also states that
her husband does not care about her but he becomes more responsive when her depression
worsens. She denies a history of drug or alcohol abuse. Beside the history of recurrent
depression in both parents, the client reports that one sister is a recovering alcoholic. She also
denies a history of physical abuse, sexual abuse, or intimate partner violence.

Mental Status Examination and Client Strengths :

Ms. Example presented as a short, overweight, white female, who appeared older than
her stated age. She was appropriately dressed in a skirt and blouse and appeared well-groomed
with the exception of dirty fingernails. She initially appeared visibly anxious and described
feeling dizzy during the early part of the interview. She attended the interview alone. The client
demonstrated poor eye contact and appeared to be shy. Despite some shyness, she was
cooperative throughout the interview and appeared to be shy. Despite some shyness she was
cooperative throughout the interview and appeared to be an organized and reliable historian.
She appeared to be average intelligence. Her mood was dysphoric and affect broad. Her speech
was logical, coherent, relevant, and goal directed. Recent memory and concentration were
impaired, while remote memory was grossly intact. Judgment was fair, although insight into her
problems was poor. She was oriented to time, place, and person, with no evidence of formal
thought disturbance. She denied experiencing delusions or hallucinations. She admitted to
current infrequent, passive suicidal ideation but denied current suicidal plan or intent. She
further denied any homicidal ideation, plan or intent. Her strength include her supportive
relationships with her children and mother, her stated desire for help, and previous positive
response to therapy.

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

Tentative Treatment Goals and Strategies

It is recommended that the client be accepted for individual therapy on a priority basis,
with the goals of reducing depressions, reducing social isolation, and increasing assertive
communication. Because she responded well in the past to cognitive-behavioral approach, this
method should be considered. Further, a referral for psychiatric evaluation for consideration of
antidepressant therapy is recommended. The clients level of suicidal thinking should be closely
monitored and regularly reevaluated.