Biopsychosocial Summary Sample

837 Words2 Pages

Biopsychosocial Summary
Paulette Erwin
University of Pacific














Christina Howell, a 32-year-old Caucasian female in office today for scheduled appointment. Was referred by Child Protective Services Social Worker. Client was dressed appropriate for time of day but clothing had holes and was notably dirty. Client also appeared to have poor personal hygiene. Client reports she feels like a worthless mother after Child Protective Services removed her 6-month-old son from her custody. Client reports she feels depressed and was diagnosed with Manic Bipolar Disorder in 2008. Client talked in a low voice and avoided eye contact. I provided an overview of the assessment tool and why this type of information is important for a treatment plan. …show more content…

Client reports she is not currently taking any prescribed or over the counter medications. She reports she drinks alcohol and smokes marijuana daily. Client stated smokes cigarettes but when she was young she hated the smell because her step-grandfather smokes in the house.
Client has one older sister who she stated she lost contact with several years ago. She moved in with her grandmother and step-grandfather when her parents divorced when she was 9 years old. Christina stated she has been estranged from her mother since that time. Client began to pick a sore on arm as she talked about her family. Provided praise for the client taking about such a difficult issue. Client described her father as someone she barely knew and who would occasionally visit her and her sister on holidays. She became nervous as she started talking about her step-grandfather who she report verbally and sexual abused her from the age 9 until she moved out at the age of 18. Client reported she seen Dr. Snow after she moved out for 2 years and felt it was beneficial She stated she told her grandmother about the abuse but her grandmother accused her lying. Client did not become overly emotional when talking

Open Document