PSYC FPX 4300 Assessment 1 : What’s Your Problem (Diagnostic Assessment)

Assessment Worksheet

Client Name: Zainab

Assessment Date: 12.29.22

Substance Use History:

Follow-on question:

1) Have these drugs ever been used in combination? These have not been used in combination with any other drug.

Medical Concerns (Describe any medical concerns that might relate to substance use.) She does not have any personal medical concerns in relation to substance use.

Past Treatment History (Describe any past treatment history for substance use, mental health concerns, or other related issues.)

She does not have any known history of treatment for medical or health issues. Never diagnosed with any disorder or health-related problem. Has been to a therapist.

Environmental Factors

Residential (Describe their living situation.)
She currently lives with her mother and father in a low-income household.

Social support system (Describe their social support system including family, friends, social groups.)

Her friends all use Adderall in order to get through school. Other peers call her names such as “poor white trash” (Capella Case Study).

Family and Family History

Family History of Use (Describe if family members use or have a history of using substances.) The mother uses Xanax for anxiety, and the father drinks in the evening but does not mention how much.

Family Mental Health History (Describe if family members have a current or past history of mental health problems and/or treatment.)
Her mother mentions that she suffers from anxiety and is currently using Xanax as treatment.

Current Additional Status to Consider

Educational (Describe client’s educational level and if they are currently in school.) The client is currently a senior in high school.

Financial (Describe client’s employment and financial situation.) She describes herself as coming from a low income, “poor” family.

Legal (Describe if client has current or past legal problems.) There is no mention of past legal problems.

Motivation for Treatment (Describe if the client thinks they have a problem, if they plan to stop or reduce their use of substances, and why they are seeking treatment. This should be two to three paragraphs.)
Her parents are seeking treatment for because they feel she needs help. She does not feel she has a problem and is reluctant. She feels she needs Adderall in order to function.

Clinical Assessment (Describe the client’s diagnosis, if any, as well as client’s existing coping skills and strengths. This should be two to three paragraphs.)

The client is a 17-year-old female, currently still in high school. Her family life is remarked as low-income, but her parents show they care about her health in order to get her treatment. She is currently using a prescription-only medication, Adderall, in order to function. She feels this is the only way to keep up with her workload at school. She does not, however, receive this medication for her own prescription and is getting it illegally at school. Her diagnosis is substance abuse of a non-prescribed prescription drug, Adderall (DSM-5). The ICD-10 notes that the code for substance abuse is F19 (ICD-10).

The patient is currently in denial of needing treatment. She is eager to be the best at school and has good intentions for needing to take Adderall. However, she has become dependent on them in order to get through her day. She has a supportive family, but her friends are all currently using Adderall as well. Due to the stress of trying to be popular and live up to higher standards, she is putting a lot of stress on herself to be the best.

References

DSM-5 (2022). https://dsm-psychiatryonline-org.library.capella.edu/

Capella University (2022). https://media.capella.edu/CourseMedia/psyc- fpx4300element238159/wrapper.asp

ICD-10 (2022). https://www.cms.gov/medicare/coding/icd10?redirect=/icd10

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