Sam Price24

							Sam Price 555 Main Street Modesto, Ca 95350 (209) 555-5555

28 Male Single Phlebotomist

Presenting Problem: Client reports problems staying focused in lengthy course and carelessness in everyday life. Client declares that he wants to learn to deal with this on his own himself. Client notes that reported activities such as squirming in seat, daydreaming, getting out of seat during class, and fidgeting with hands made his last semester of college (4/01) extremely difficult. Reportedly he feels very anxious regarding these activities and unsure of why he is so restless lately. Client states that he wants to resolve this issue before applying to medical school, because he doesn’t think he could fulfill his obligations while dealing with the inattention. He reports an association with thoughts of medical school and increased anxiety. He discloses that he has previously tried to reduce anxiety and focus using exercise. Client’s Current Life Setting: Client reports that in June of 2001 he moved in with his parents and has been residing there. He has his bachelor’s degree in Microbiology and has plans to attend medical school. Currently he reports working full time as a Phlebotomist at St. Don’s Hospital where he has worked for the prior 3 months. Client professes to running and working out 4-5 times a week. Currently he reports taking one herbal medication for weight loss and a recent physical that turned up no physical defects. Currently he discloses that he is single and dates around two times a month. Client also reports a tight knit group of friends that he sees throughout the week. Client denies any current suicidal or homicidal ideation. Family History: Client is Assyrian, 3rd generation, believes in a higher power, but does not practice any religion or spirituality. Client reports that he came from a “normal” family. He reports being the oldest and having a brother 3 years younger (Business Major) and a younger sister both of which he is still close to. He reports that he was a “handful” to his mother when he was younger, but that it got better as he got older. He reports anxiety with his father surrounding his applying to medical school. He reports that his father is strict and has his own idea for what he should be doing with his life. He discloses that he does not feel that his father hears him when he asserts his needs. Client reports no history of mental illness in family to the 2 nd degree that he is aware of. Client reports the move home was stressful because of conflicts with mother regarding his schedule. However, client notes that his mom “treats him like a king” and just wants what is best for him. Personal History: Client reports no broken bones or serious illnesses throughout life. Client discloses that he had trouble in school at an early age, but that with the introduction of sports to his life his problems went away. He completed high school as a better than average student while participating in football, baseball and other extracurricular activities. He cites that his coaches were essential in keeping him on track with his schoolwork. Again, in college he reports participating in educational as well as sports activities. He reports that his last semester of

college the seasons ended and he no longer had that coach influence. Client denies any military service. Client reports having his first job at 18 years old and working as a Phlebotomist for the last 4 years. He states that he is one of the best employees and having little difficulties at work past or present. Client reports being single currently and having trouble picking between all the girls who would like to date him. Client denies any history of prior counseling. Client discloses first trying alcohol after graduating high school. Client reports alcohol use of 2 -3 12-ounce beers once a week. Client denies any other drug use, including steroids. Clients reported goals in life include making a lot of money and being happy. Description of the client during the interview: Client came timely for the interview dressed in a print T-shirt and a pair of black nylon pants. Client had no noticeable defects. Client shook hands with writer and made eye contact throughout the interview. Client answered questions when asked and displayed variability in affect when relating answers. Client appeared to be smiling throughout the interview. Perceptual or sensory interference were not evident from the interview. Client reported information as asked and expounded on information when prompted. Client spoke at a socially appropriate speed and volume and appeared coherent throughout. Summary and Recommendations: Client would benefit from a “coach” someone giving him skills to handle the issue by himself. A cognitive behavioral approach would be appropriate considering a possible diagnosis of Attention-Deficit Disorder. Unfortunately, without the help of the parents finding the onset, symptoms and extent of the issue would be impossible. The client would first benefit from relaxation techniques to combat the anxious feelings that do not require him getting out of his seat. Furthermore, using cognitive restructuring techniques. Also, some basic goal setting and also trying to tie him back into his social network for a new “coach.”