Jane Jones
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School
Central State University *
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Course
5004
Subject
Communications
Date
Feb 20, 2024
Type
docx
Pages
3
Uploaded by namyawright
Name
: Jane Jones DOB
: 07/06/1995 MRN
:1234567 Contact Information
: (414) 111-2222 Referred by/Reason
: Referred by MHEC, in need of support with housing, jobs and medication monitoring. Consent: I cannot and will not tell anyone else what you have told me, or even that you are having a session with me without your prior permission.Unless you are a danger to yourself or others. You can authorize me to share information with whomever you choose, and you may change your mind and revoke that permission at any time. Jane Jones agreed and understood. Identifying information
: NaMya BS in science, Jane Jones and her parents were in the session. Session was completed at Capella Therapy Inc. 12/08/23 an hour and thirty minute session. Jane is a 28 year old african american female who is in need of assistance with housing, jobs and medication monitoring. Jane is single and currently lives with her parents. Jane describes herself as a happy person who enjoys being around family. Her life vision includes moving into her own
apartment and to get a job. She believes her strengths include being smart, dedicated and nice. Jane reported her life satisfaction is a 6/10 as she no longer feels independent relying on her parents. Her coping skills include listening to music, smoking cannabis and coloring. Jane is experiencing depression. She stated she is depressed being that she feels like she lost her independence and her parents are trying to control her. In 2022 Jane moved back in with her parents because she lost her job and could no longer support herself. She copes by coloring and listening to music when she feels overwhelmed. Jane's parents feel like she is giving up on achieving her goals. They believe they’re encouraging her while also providing her with tough love. They do believe they have been harder on her lately but stated it's in her best interest.
Background History
: From an early age Jane reports her family being supportive and loving. As she got older they demanded perfection from her. Anything below a B grade in school was unacceptable. Jane stated she always felt the need to be perfect and not a disappointment to her family. Jane knows her family loves and supports her but does not understand why they are hard on her.
Education/Work history
: Jane graduated from the University of Milwaukee Wisconsin with her bachelors in criminal justice. She is not currently working but is actively looking for work. Previously she worked at an amazon warehouse but was laid off due to having too many employees. AODA
: Jane reports smoking cannabis but only when she is stressed. Jane has not received treatment being that she does not see an issue with her use.She began smoking in college 2017. She last smoked three days ago. She stated she would cut back if she was less stressed. The parents stated it does not directly impact them but does not like that she does it.Jane’s psychiatrist educated her on the risk of smoking while taking antidepressants. Jane understands but does not want to stop yet. Jane's parents would like her to receive outpatient services.
Biomedical
: Jane currently has no biomedical issues She sees her primary doctor, dentist, allergist and optometrist as scheduled. She is allergic to trees, cats and roaches. Hypertension runs on her mothers side of her family but she has not been diagnosed. Mental health history
: She was diagnosed with seasonal depression by her psychiatrist. The psychiatrist prescribed her prozac. Her family has a history of anxiety and depression. She noticed her depression began when her college best friend passed away in 2020. She graduated May of 2021 and glad she accomplished her major goal. Spirituality
: Jane attempts to go to church every sunday and plans on getting closer to God. Psychosocial / Developmental History : Jane stated she was in one serious relationship in college and it ended mutually on good terms. She currently does not want to be in a relationship so she can focus on herself. Jane reports being emotionally abused in middle school. They would
make fun of her for being quiet. She then met friends who made her feel welcome. Jane has no legal history. Client reported her key issue is not having a job to provide for herself. The provider feels like her key problem is the lack of motivation and pressure given by her parents. The client functions and can complete basic ADL skills. The lack of motivation, the high expectations given by the family, and the stressor of not being enough are all contributing to the problems she is currently having. Jane's strengths are the ability to understand she needs help. Jane would benefit greatly from intervention. Jane understands she is in need of help but lacks the motivation to make real change. With change this writer believes that Jane will make great progress within her personal life. Jane does not have nor ever had suicidal ideations. Psychiatric history
: Jane has not been hospitalized for her mental health. Jane's family mental health includes anxiety and depression. Jane has been diagnosed with depression and is currently
taking prozac. Grooming
: Jane was dressed appropriately and had good hygiene. Behavior
: J
ane was cooperative and engaged in the conversation. Jane provided good eye contact. Speech
: Normal Rate Psychomotor: No Abnormalities or
psychomotor agitation or retardation
Mood: Euthymic
Affect:
Congruent
Thought process: Appropriate
Thought content: Appropriate Suicidal ideation: Denies Homicidal Ideation: Denies Insight: Intact Judgment: Not impaired Concentration and attention: within normal limits
Memory: Intact Impulse control: Intact Intelligence: Above Treatment plan
/intervention:
296.41Mild Depression Jane was presented with a depressed mood, loss of interest, and feeling wo
reduce her symptoms. The treatment plan matches the diagnoses. The treatment plan and intervention is evidence
will attend therapy once a week every wednesday. The discharge criteria will include the client achieving her goa
the client and this writer to make clear steps in each step to make a linear path to completion. Intervention
: Jane identified her two goals as living in her own safe environment and getting a job. The social worker will assist this client with providing her with resources for housing.The case manager will provide her with housing within her budget. The social worker will assist Jane
with updating her resume if needed. Jane will begin to look for a job and save enough money for a deposit and any other necessities she needs. Provider signature_____
NaMya Wright
___________
Hollon, S. D. (2022) stated that “
Beck initially set out to test the Freudian notion that depression
is a consequence of “anger turned inward” (rage directed the introjected parent for not gratifying infantile desires)” Research stated that cognitive therapy worked well enough for patients who did not have severe problems. “ That said, more was needed for patients with depressions superimposed on longstanding personality disorders. This lacuna was addressed in his subsequent classic Cognitive Therapy of Personality Disorders (
Beck et al., 1990
).” Tims story is similar to Jane Jones.
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