Clinical Record: Psychosocial History

Name: Judy Young
ID: 100
SSN: 333-33-3333
Date: 7/8/2001
Page #: 1 of 9
Clinical Record
Name: Mrs. A
Provider: Jesse R. Mellor , PhD
Date: 5/3/2005
REPORT
Personal Data
ID: 100
Address: 1111 Main St
City:
State:
Zip:
Home Phone:
Work Phone:
SSN:
Grand Rapids
MI
55555
555-555-5555
555-555-5555
333-33-3333
Birth Date:
Age:
Gender:
Race:
Marital Status:
Military Rank:
Treatment Start Date:
Treatment End Date:
Last Review:
Treatment Status:
Previously Treated?:
Pri. Care Physician:
Employer:
Referral Source:
Psychiatrist:
Setting:
Department:
11/13/1969
35
Female
Caucasian
Married
NA
4/13/2001
Active
No
Dr Boss
Unknown
Self
Dr John Lightfoot
Outpatient
Northeast Office
Authorization Data
Insurance Carrier
Date Authorized
Start Date
End Date
Priority Health
5/01/2005
5/03/2005
6/17/2005
Total Sessions Authorized This Episode: 10
Authorized Sessions
10
Sessions Used: 1
Authorization Number
665
Sessions Remaining: 9
Assessment
Interviewer: Edwin Melndez, M.Ed
Interview Date: 5/03/2005
Person Interviewed: Patient
Psychosocial History:
Family:
Client was self-referred to our agency for symptoms of mild depression associated with Histrionic Personality Disorder. During
this time is showing poor boundaries and appears to empathetic towards wanting to get help. However, she is currently facing
difficulties in her life around her appearance and with long-term relationships not lasting.
Developmental:
N/A
Substance Use:
N/A
Socio-Economic:
Client lives alone and she has completed a college degree in business and has worked in an advertising firm for 3 years.
Client is active in her church and has many friends through this resource. They have reduced their social activity significantly
since Mrs. A depression began.
Psychiatric:
N/A
Medical:
No critical medical issues are present.
Strengths/Weaknesses
Strengths:
Motivated for Change, Responsible
Weaknesses:
Impulsive, Dependent
Name: Judy Young
ID: 100
SSN: 333-33-3333
Date: 7/8/2001
Assessments Completed:
Instrument/Interview: Clinical Interview
Date Administered: 05/03/2005
Result:
Details:
Data Source: Patient

Treatment Phase: Post-Treatment
Client was reserved in giving the history of her depression.
Instrument/Interview: Symptom Checklist-90-R: Global Severity Index

Date Administered: 4/13/2001
Result: 22
Treatment Phase: Pre-Treatment
Details:
Date Administered: 4503/2005
Result:
Treatment Phase: Post-Treatment
Details:
Date Administered:05 /03/2005
Result: 11
Treatment Phase: Follow-up
Details:
Interpretation Note:
Judy is showing good improvement over time in her SCL-90-R GSI scores.
Mental Status:
Presentation
Date First Rated: 4/13/2001
Date Last Rated: 4/24/2001
Well-Groomed
Well-Groomed
Depressed
Depressed
Attitude:
Cooperative
Cooperative
Affect:
Appropriate
Appropriate
Slow
Normal
Restless
Tense
Fully Oriented
Fully Oriented
Simple Calculations:
Accurate
Accurate
Serial Sevens:
Accurate
Accurate
Immediate Memory:
Intact
Intact
Remote Memory:
Intact
Intact
Appearance:
Mood:
Speech:
Motor Activity:
Orientation:
Mental Functioning
General Knowledge:
Accurate
Accurate
Proverb Interpretation:
Accurate
Accurate
Similarities/Differences:
Accurate
Accurate
Judgment:
Intact
Intact
Insight:
Intact
Intact
Intelligence:
High
High
Logical And Organized
Logical And Organized
None Evident
None Evident
None Evident
None Evident
Higher Order Abilities
Thought Form/Content
Thought Processes:
Delusions:
Hallucinations:
Risk Assessment
Date First Rated:
Date Last Rated:
Page #: 2 of 9
Name: Judy Young
ID: 100
SSN: 333-33-3333
4/13/2001
4/24/2001
Suicide:
Slight
None
Violence:
None
None
Child Abuse:
None
None
Partner Abuse:
None
None
Elder/Parent Abuse:
None
None
Date: 7/8/2001
Page #: 3 of 9
Latest Note
Most Recent Mental Status Summary:
Assessment Summary:
Diagnosis
Axis I
Axis II
300.4
V71.09
Axis III
None
Axis IV
Economic Stress
Dysthymic Disorder
No Diagnosis
Stress Severity Rating: 3

Axis V
Current: 51-60
Moderate
Prior: 61-70
Treatment Techniques
Treatment Modalities:
CPT Code
90806
90847
Type
Indiv. OP Psychotherapy-45" no Med. Eval
Family or Conjoint Therapy - with Patient
Recommended
Level of care
Outpatient
Least Restrictive
Alternative?
Frequency
1 Weekly
1 Monthly
Agreement with
level of care?
Yes
Provider
Arthur E. Jongsma, PhD
Is recommended level
of care available?
Yes
Modality Note:
Treatment Approaches:
The following treatment approaches are being implemented:
Cognitive Restructuring
Medication: Prozac
Start Date: 4/13/2001
Note:
Dosage: 40mg
End Date:
Frequency: Daily
Prescribed by: Dr Boss
Medication: Desyrel
Start Date: 4/24/2001
Note:
Dosage: 20 mg
End Date:
Frequency: At hs
Prescribed by: Dr Boss
Desyrel has been added to aid in sleep induction.

Approach Note:
Presenting Problems
Primary
Secondary
Other
Depression
Financial Stress
Chronic Pain
Dependency
Treatment Plan
Primary Problem:
Depression
Behavioral Definition
Yes
Name: Judy Young
ID: 100
SSN: 333-33-3333
Date: 7/8/2001
Page #: 4 of 9
Loss of appetite.
Diminished interest in or enjoyment of activities.
Poor concentration and indecisiveness.
Feelings of hopelessness, worthlessness, or inappropriate guilt.
Social withdrawal.
Depressed affect.
Low self-esteem.
Sleeplessness or hypersomnia.
Long-term Goals
Alleviate depressed mood and return to previous level of effective functioning.
Develop the ability to recognize, accept, and cope with feelings of depression.
Develop healthy cognitive patterns and beliefs about self and the world that lead to alleviation of
depression symptoms.
Short-Term Objectives/Therapeutic Interventions
Describe the signs and symptoms of depression that are experienced.

Entry Date: 4/13/2001
Target Date:
4/30/2001
Projected Sessions: 2
Critical?: Yes
Explore how depression is experienced in patient's day-to-day living.

Provider: Arthur E. Jongsma, PhD
Encourage sharing feelings of depression in order to clarify them and gain insight as to causes.
Verbally express understanding of the relationship between depressed mood and repression of
feelings-that is, anger, hurt, sadness, and so on.
Target Date:
5/3/2001
Critical?: No
Encourage patient to share feelings of anger regarding pain inflicted on her in childhood that
contributes to current depressed state.
Explain a connection between previously unexpressed (repressed) feelings of anger (and

helplessness) and current state of depression.
Identify cognitive self-talk that is engaged in to support depression.

Target Date:
5/28/2001
Critical?: Yes
Assist in developing awareness of cognitive messages that reinforce hopelessness and

helplessness.
Replace negative and self-defeating self-talk with verbalization of realistic and positive cognitive
messages.
Target Date:
7/3/2001
Critical?: Yes
Help the patient keep a daily record that lists each situation associated with the depressed feelings
and the dysfunctional thinking that triggered the depression. Then use logic and reality to
challenge each dysfunctional thought for accuracy, replacing it with a positive, accurate thought.
Assign patient to keep a daily journal of experiences, automatic negative thoughts associated with
experiences, and the depressive affect that results from that distorted interpretation. Process
journal material to diffuse destructive thinking patterns and replace with alternate, realistic,
positive thoughts.
Assigned homework for From Here to Where?

Provider:
Make positive statements regarding self and ability to cope with stresses of life.
Target Date:
7/17/2001
Critical?: Yes
Name: Judy Young
ID: 100
SSN: 333-33-3333
Date: 7/8/2001
Page #: 5 of 9
Reinforce positive, reality-based cognitive messages that enhance self-confidence and increase
adaptive action.
Assign patient to write at least one positive affirmation statement daily regarding himself/herself
and the future.
Decrease frequency of negative self-descriptive statements and increase frequency of positive

self-descriptive statements.
Target Date:
6/17/2001
Critical?: Yes
Assign exercise of patient talking positively about self into a mirror once per day.
Reinforce patient's positive statements made about self.

Assign patient to write at least one positive affirmation statement daily regarding himself/herself
and the future.
Assigned homework for Define Failure/What Kept You From It?

Implement a regular exercise regimen as a depression reduction technique.

Target Date:
Critical?: No
Develop and reinforce a routine of physical exercise to stimulate depression-reducing hormones.

Recommend that the patient read and implement programs from Exercising Your Way to Better
Mental Health (Leith).
Secondary Problem: Financial Stress

Behavioral Definition
Indebtedness and overdue bills that exceed the ability to meet monthly payments.
A feeling of low self-esteem and hopelessness that is associated with the lack of sufficient income to
cover cost of living.
A long-term lack of discipline in money management has led to excessive indebtedness.
Long-term Goals
Establish a clear income and expense budget that will meet bill payment demands.
Contact creditors to develop a revised repayment plan for outstanding bills.
Achieve an inner strength to say no to one's personal impulses, cravings, and desires which directly or
indirectly increase debt irresponsibly.
Short-Term Objectives/Therapeutic Interventions
Describe the details of the current financial situation.

Target Date:
4/24/2001
Projected Sessions:
Critical?: No
Provide a supportive, comforting environment by being empathetic, warm, and sensitive to the
fact that the topic may elicit guilt, shame, and embarrassment.
Explore the patient's current financial situation.

Assist patient in compiling a complete list of financial obligations.

Reconstruct the history of the problem in an attempt to isolate the sources and causes of the
Name: Judy Young
ID: 100
SSN: 333-33-3333
Date: 7/8/2001
Page #: 6 of 9
excessive indebtedness.
Target Date:
4/30/2001
Projected Sessions:
Critical?: Yes
Assist patient in compiling a complete list of financial obligations.

Assist in identifying, without projection of blame or holding to excuses, the causes for the
financial crisis.
Verbalize feelings of depression, hopelessness, and/or shame that are related to financial status.
Target Date:
4/24/2001
Projected Sessions:
Critical?: Yes
Probe feelings of hopelessness or helplessness that may be associated with the financial crisis.
Identify priorities that should control how money is spent.

Target Date:
6/1/2001
Projected Sessions:
Critical?: Yes
Ask patient to list priorities that she believes should give direction to how money is spent. Process
those priorities.
Assigned homework for Where Does It Go?

Write a budget that balances income with expenses.

Target Date:
6/18/2001
Projected Sessions:
Critical?: Yes
If financial planning is needed, refer to a professional planner or ask partners to write a current
budget and long-range savings and investment plan.
Review budget as to reasonableness and completeness.

Identify personal traits that make undisciplined spending possible.

Target Date:
5/15/2001
Projected Sessions:
Critical?: Yes
Probe for evidence of low self-esteem, need to impress others, loneliness, or depression that may
accelerate unnecessary, unwarranted spending.
Acknowledge impulsive spending as part of a general pattern of impulsivity that is based on mood
swings.
Target Date:
Projected Sessions:
Critical?: No
Assess for mood swings that are characteristic of bipolar disorder and could be responsible for
careless spending due to impaired judgment of manic phase.
Keep weekly and monthly records of financial income and expenses.

Target Date:
5/7/2001
Projected Sessions:
Critical?: Yes
Encourage patient to keep weekly and monthly record of income and outflow. Review records
weekly and reinforce responsible financial decision making.
Response to Plan
Response to treatment plan presentation:
Judy is accepting of the treatment plan.
Significant Other response to treatment plan presentation:
Jack is supportive of the treatment plan.
Name: Judy Young
ID: 100
SSN: 333-33-3333
Date: 7/8/2001
Page #: 7 of 9
I, Judy Young, have reviewed this treatment plan.

x. _______________________________________________
Date: ______________________________
Progress Notes
Session 1
Date: 4/13/2001
Time: 2:00 PM
to 3:00 PM
(60 min)
Modality: Individual Therapy

Problem Addressed: Depression
Progress Rating: No Change

CPT Code:
Patient Presentation (Signs and Symptoms):

The patient reported that she has not had a normal and consistent appetite.
The patient reported a diminished interest in or enjoyment of activities that were previously found pleasurable.
The patient has withdrawn from social relationships that were important to her.
Interventions Implemented:
The patient was asked to describe her experience of depression for the signs and symptoms that are present in her daily
living.
The patient was encouraged to share her feelings of depression in order to clarify them and gain insight into their causes.
Narrative Progress Note:
Judy has described her depression symptoms including social withdrawal, sad affect, low energy and lack of appetite. I urged
her to begin a journal of her thoughts and feelings.
Provider Signature: _____________________________________________
Session 2
Date: 4/20/2001
Time: 2:00 PM
to 3:00 PM
____________________
Date
(60 min)
Modality: Indiv. OP Psychotherapy-45" no Med. Eval

Problem Addressed: Financial Stress
Progress Rating: Significant Regression

CPT Code: 90806

The patient described severe indebtedness and overdue bills that exceed her ability to meet the monthly payments.
The patients feelings of hopelessness and helplessness that are associated with the financial crisis were explored.
The patient reported that her appetite is at normal levels.
The patient has followed through with reading the recommended book on exercise and mental health and reported that it
was beneficial.
The patient was assigned to talk positively about herself into a mirror once per day.
Judy has begun journaling her thoughts and feelings. She notes that her mood is most dark in the evening. She has begun to eat
a little better.

Session 3
Date: 4/27/2001
Time: 2:00 PM
to 3:00 PM
Modality: Family or Conjoint Therapy - with Patient

____________________
Date
(60 min)
Progress Rating: Some Progress

CPT Code: 90847

The patients feelings of hopelessness and worthlessness have diminished as the depression is beginning to lift.
The Socratic method was used to challenge the patients dysfunctional thoughts and to replace them with positive,
Name: Judy Young
ID: 100
SSN: 333-33-3333
Date: 7/8/2001
Page #: 8 of 9
reality-based thoughts.
Problem Addressed: Financial Stress
The patient has a long-term lack of discipline in money management that has led to excessive indebtedness.
The patients current financial situation was explored in detail.
Jack accompanied Judy to today's session. They talked of their financial stress and indebtedness. They agreed to put together a
list of their debts and a history of payment. Later a budget will be developed together.
____________________
Date
Objective Ratings
Critical?
First Progress Rating:

4/13/2001
Last Progress Rating:

4/27/2001
the signs and symptoms of depression that are

experienced.
Verbally express understanding of the relationship between
depressed mood and repression of feelings-that is, anger, hurt,
sadness, and so on.
Identify cognitive self-talk that is engaged in to support
depression.
Replace negative and self-defeating self-talk with
verbalization of realistic and positive cognitive messages.
Make positive statements regarding self and ability to cope
with stresses of life.
Decrease frequency of negative self-descriptive statements
and increase frequency of positive self-descriptive statements.
Implement a regular exercise regimen as a depression
reduction technique.
Describe the details of the current financial situation.
Reconstruct the history of the problem in an attempt to isolate
the sources and causes of the excessive indebtedness.
Verbalize feelings of depression, hopelessness, and/or shame
that are related to financial status.
Identify priorities that should control how money is spent.
Write a budget that balances income with expenses.
Identify personal traits that make undisciplined spending
possible.
Acknowledge impulsive spending as part of a general pattern
of impulsivity that is based on mood swings.
Yes
No Change
Significant Regression
No
No Change
Some Progress
Yes
No Change
Some Progress
Yes
No Change
No Change
Yes
No Change
No Change
Yes
No Change
No Change
No
Some Progress
Completed
No
Yes
No Change
No Change
Completed
Some Progress
Yes
No Change
Some Progress
Yes
Yes
Yes
No Change
No Change
No Change
No Change
No Change
Some Progress
No
No Change
No Change
Keep
Yes
No Change
Some Progress
Projected Date for

Treatment End
% of Critical Objectives
Achieved by Treatment End
Objectives Identified
Describe
weekly and monthly records of financial income and

expenses.
Prognosis
Prognosis Rating of successful
achievement of Goals
Good
Rationale for Prognosis Rating:
Discharge
Projected Number of Sessions

before Treatment End
14
7/23/2001
80%
Name: Judy Young
ID: 100
SSN: 333-33-3333
Date: 7/8/2001
Page #: 9 of 9
Discharge Criteria:
Engages
No
in social interaction with appropriate eye contact and assertiveness.

expression of suicidal ideation.
Competency to manage self-care:

Competency to manage financial resources:
Follow-up care:
Referral Made To:
Placement Recommendation:
Vocational Plan:
Treatment End Date:
After-care Plan/ Discharge Summary:
Competent
Competent
Self Care
Return to full-time job
Provider Credentials
______________________________________________
Primary Treatment Provider
Psychologist
License: 0000 (MI)
______________________________________________
Supervisor
William P. McInnis, PsyD
Psychologist
License: 1111 (MI)
Clinical Notes
Judy has been treated on an inpatient basis at St. Mary's Hospital for two weeks for depression in March of 2000.

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What is the patient's diagnosis and treatment history?

What is the patient's diagnosis and treatment history?

What assessments were conducted on the patient?

What assessments were conducted on the patient?

Name: Judy Young

Provider: Jesse R. Mellor , PhD

Total Sessions Authorized This Episode: 10

Interview Date: 5/03/2005

Person Interviewed: Patient

No critical medical issues are present.

Name: Judy Young

Data Source: Patient

Client was reserved in giving the history of her depression.

Instrument/Interview: Symptom Checklist-90-R: Global Severity Index

Date First Rated: 4/13/2001

Date Last Rated: 4/24/2001

Date First Rated: 4/13/2001

Date Last Rated: 4/24/2001

Date First Rated: 4/13/2001

Date Last Rated: 4/24/2001

Date First Rated: 4/13/2001

Date Last Rated: 4/24/2001

Logical And Organized

Logical And Organized

Higher Order Abilities

Date First Rated:

Date Last Rated:

Name: Judy Young

Most Recent Mental Status Summary:

Stress Severity Rating: 3

Desyrel has been added to aid in sleep induction.

Name: Judy Young

Short-Term Objectives/Therapeutic Interventions

Describe the signs and symptoms of depression that are experienced.

Explore how depression is experienced in patient's day-to-day living.

Provider: Arthur E. Jongsma, PhD

Provider: Arthur E. Jongsma, PhD

Provider: Arthur E. Jongsma, PhD

Explain a connection between previously unexpressed (repressed) feelings of anger (and

Provider: Arthur E. Jongsma, PhD

Identify cognitive self-talk that is engaged in to support depression.

Assist in developing awareness of cognitive messages that reinforce hopelessness and

Provider: Arthur E. Jongsma, PhD

Provider: Arthur E. Jongsma, PhD

Provider: Arthur E. Jongsma, PhD

Assigned homework for From Here to Where?

Name: Judy Young

Provider: Arthur E. Jongsma, PhD

Provider: Arthur E. Jongsma, PhD

Decrease frequency of negative self-descriptive statements and increase frequency of positive

Provider: Arthur E. Jongsma, PhD

Reinforce patient's positive statements made about self.

Provider: Arthur E. Jongsma, PhD

Provider: Arthur E. Jongsma, PhD

Assigned homework for Define Failure/What Kept You From It?

Provider: Arthur E. Jongsma, PhD

Implement a regular exercise regimen as a depression reduction technique.

Develop and reinforce a routine of physical exercise to stimulate depression-reducing hormones.