Initial Psychosocial Assessment Questionnaire
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
Initial Psychosocial Assessment Questionnaire
Client: Peggy Jean James Intake Date: 09/25/2018
Date of Birth: 09/08/1934 Age: 84 Sex: Female Race: Caucasian
Interviewer: Erica Allen
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Current Family/Support System: (Current family household composition and relationships)
Peggy James is the daughter of Benjamin H. and Jimmie James. Both of her parents are still living and in their nineties. She has two twin sisters that are eighty years old named Catherine and Caroline. Catherine lives in Houston, TX and Caroline lives in North Carolina. Peggy is currently a resident at Quince Nursing Home & Rehabilitation Center in room 902 B. The address in 6733 Quince Road, Memphis, TN 38119.
Presenting Problem: Short statement about immediate concern, current situation, and by whom referred. (List symptoms/onset/duration/precipitating events/current stressors)
Client Interview: Peggy James told me that she needs go to the salon and take a bath. Peggy James is divorced from her husband after eleven years of marriage. They were high school sweethearts and married at 21. She said that she regrets marrying him because she was unhappy the entire time. Then, she starting dating her “best friend”, Marietta Griffin. They were in a romantic relationship for 40 years up until her death in 2015. Marietta was also Peggy’s live-in caregiver. She was very vague and hesitant to provide many details. However, she always smiled when she mentioned her name and pointed to her pictures on the wall. Peggy said that she’s a member of Bellevue Baptist Church and sang in the choir. Her favorite song is “The Lord’s Come for Me”. Her favorite scripture is Psalm 46: 1-3.
Current Level of Functioning: (Assess sleep/appetite/mood/energy/substance use)
Sleep: Gets about six hours of sleep at night
Appetite: Eats three meals per day
Energy Level: Low because she has some mobility issues; hurts to walk due to swelling in legs and feet
Attention: Alert
Mood: Upbeat
Hallucinations/Delusions: The client did not exhibit any signs of hallucinations or delusions in my presence.
Other: Dementia
Risk Assessment:
Suicidal Ideation: Ms. James did not mention any thoughts of hurting herself.
Homicidal Ideation: Ms. James did not mention any thoughts of killing anyone else.
Safety Plans:
Mental Health Treatment History:
History of Problems/Age at First Diagnosis: Yes. Ms. James was diagnosed with dementia in 2015.
Past Outpatient Treatment: No. Ms. James did not mention a previous history for hospitalization for mental illness.
Past Inpatient Treatment: No. Peggy didn’t mention any past history of inpatient hospitalizations for any medical conditions.
Family History of Mental Health treatment/Diagnosis: No. Ms. James did not mention any family history of mental illness.
Relevant History:
Family Issues: Yes. Peggy does not have a good relationship with her sister catherine that lives in houston, Tx. She refers to her as “the mean one”. However, she speaks very highly of her sister caroline, that lives in north carolina.
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Physical Abuse: No. Ms. James denied any history of physical abuse.
Sexual Abuse: No. Ms. James denied any history of sexual abuse.
Other Trauma: Yes. In 2015, Marietta Griffin, Peggy’s lesbian lover of 40 years, died in front of her after choking on some pills.
Educational History: Peggy James graduated from Millington central high school in 1952.
Medical History:
Present Physical condition: Peggy James has some swelling/edema in both of her legs and feet. But she is mobile and fairly healthy.
History of Illness, Injury, or Surgery: Yes. Peggy James was diagnosed with dementia in 2015.
Medications: (Six month history of prescribed and over-the-counter medication including dose prescriber/when taken/illness/results): takes water pills, uses Betamethasone Valerate Ointment 1% for a rash on face, hands, and feet.
Legal History:
Current or Pending Legal Involvement: No. The aging commission of the mid-South is her conservator because she is not able to take care of herself.
Past Legal Involvement: No
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Alcohol and Drug History and Current Use:
(Include all drugs ever abused/onset of use, average quantity and frequency/last use/route of administration)
Peggy James denied any past or present history of drug and alcohol abuse.
Employment History:
She was employed as an administrative assistant to the director of the finance department at MLGW for 17 years.
Summary and Intervention Recommendations:
Peggy James is an eighty-four year old, Caucasian female that lives at Quince Nursing Home and Rehabilitation Center located at 6733 Quince Road in Memphis, TN in room 902 B. She got divorced after eleven years of marriage and does not have any children. Both of her parents Benjamin H. and Jimmie James are still living and are in their nineties. She is the eldest sibling of her two twin sisters, Caroline and Catherine, age eighty. Sadly, Peggy witnessed the untimely death of her romantic partner, Marietta Griffin in 2015. Marietta choked on some pills in front of Ms. James which contributed to her mental decline because Ms. Griffin was her live-in caregiver too. Peggy is also a member of Bellevue Baptist Church and used to sing in the choir.
TREATMENT GOAL:
Peggy James needs to attend individual therapy to address her feelings of guilt surrounding her partner’s death. She also needs to attend grief counseling because she has not allowed herself to release as a result of her traumatic loss. Ms. James repeatedly stated that she wanted to “leave the facility and go back home”. Peggy could also benefit from some physical therapy to strengthen her mobility.
TREATMENT ACTION STEPS:
Peggy will recite a poem about love each time she gets the urge to cry about Marietta’s passing.
Peggy will sing her favorite song, “The Lord’s Come for Me” to lift her spirits when she wants to cry.
Peggy will read Psalm 46: 1-3 to cheer her up when she thinks about Marietta and her current situation.
Clinician Signature: ______________________________________________ Date: __________________