Sandra is a 35 year old mother of three who was came into the office due to feeling sad and crying frequently. She was neatly dressed but appeared tense. She was a tall woman of average weight. She was open with the clinician and stated tearfully that about one week about she was forced to move out of her home because of old roof damage caused by a past hurricane. She stated that a recent storm caused the roof to begin leaking so badly that water came into the home. The fire department was notified by a neighbor. She stated that the fire inspector told her that she had to leave and condemned her home. At this point in the interview her rate of speech and tone increased significantly. She was however on task when speaking. She kept to the subject well. She stated that since the fire inspector came she has been unable to sleep, feels jittery, sad, cries all the time, and has heaviness in her chest various times throughout the day. She has been to the emergency room twice, but they find nothing wrong.
During the clinical interview Sandra appeared attentive to the conversation. She shared with the clinician that the house she was forced to leave was her mother’s childhood home. She stated that her mother moved into this home when she was five years old with her grandparents. She stated that her grandparents immigrated into America when her mother was a small child to have a better life. Sandra’s memory appeared very vivid when she recalled details of the happiness that she had in the home with both her mother and her own children. She stated that although the house was old and damaged she loved it dearly and reminded her everyday of her mother. She shared that her mother died five years ago of cancer and left the home to her. She stated that she has tried very hard to keep the home in good condition but the hurricane damaged it so much she didn’t know what to do. Sandra face appeared very flat when discussing her prior experiences with the house. She was able during this conversation able to provide information on her current whereabouts, time of day and particulars situation that she was in.
Sandra stated that she has no past history of mental illness or mental health treatment. She shared that she lives with mild diabetes, but controls it at this point with diet and exercise. She is not taking any medication. She was able to provide the clinician with good detail and content during the conversation. Sandra stated that she is currently in a Red Cross sponsored hotel. She denied hearing voices or believing things that others would think to be untrue. She stated that she did not know where to go with her children, as her house was the only place they knew of as home.
Sandra stated that she is a medical technician for a doctor in West Palm Beach, Florida. She stated that she has worked for the doctor for ten years. She is making $14.00 an hour. She stated that she completed high school and two years of vocational training. She stated that she is taking college courses one at a time at the community college. She stated that she has very little savings. She stated that her mother left her a trust but she has no access to it until she is 40 years old. She stated that she had called the insurance company for the home, but that she had to wait on hold for a long time and couldn’t because she was working. She stated that she feels as if she is going to be homeless and going to have to live on the street with her children. She stated that when she attempts to make any decisions that might help her she gets chest pains, lies down and cries.
Sandra stated that she has few supports in the area. She stated that although she is an American citizen she was born in India. She said that she was adopted by her mother when she was one year old while her mother was in India. She stated that her mother lived and worked in India for five years as a scientist but decided when Sandra was 3 to return to America to take care of her own parents who were at that time elderly. She is an only child.
Sandra shared that her own children were adopted when she was 29 years old. Sandra stated that her mother was a foster parent and was fostering these three children for about five years before she became ill. Sandra stated that she adopted them prior to her mother dying so that they could stay with her. She began to cry at this point again and stated that she couldn’t stand the thought of losing her children. Sandra stated that she did not know her own biological father as he lives out of the country. Sandra attends religious services on a regular basis. She stated that she tries to find peace within her spirituality, but finds everything so hard to do.
Complete the following on Sandra:
Mental Health Status Exam
Multiaxial Evaluation
Initial recommendations
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