Bio-Psycho-Social and Plan of Change

Bio-Psycho-Social Assessment SW 3020 2/20/13 004307498

Presenting Problem

Bio-Psycho-Social and Plan of Change

John Doe (pseudonym) is a 24 year old single Caucasian male. John lives at home with his Mother and Father. John is here to see me today because he is saying he thinks he is depressed and fears he is on the wrong path of life.

Family of Origin History John was born when his mother was 26 and his father was 28. His parents were married at the time and they are still married today. John says that to his knowledge his birth was planned. Johns dad has worked as a manager for a forklift company for the past 20 years. His mother has had a couple of different jobs since his birth. When he was born she spent time off for a while to raise him. Once he was a little older, she started to work at Kmart. She then acquired another job when he was around the age of ten as a receptionist at a hair salon. She still currently works two jobs. Both parents graduated high school but never sought a college education. His parents are currently 50 and 52 years old and they have no health issues to his knowledge. John says he was raised in a very good atmosphere. His parents loved him and loved each other. Because they worked long hours he spent a lot of time with his grandparents. He says he celebrated all of the traditional American/Christian holidays with his family. The client was never faced with the deaths of any loved ones during his childhood and he denies any abuse during his childhood. He considers himself to be close with his family but he finds trouble relating to them often.

Developmental History

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John was born vaginally in what was a lengthy process. The client was near eight pounds at birth and there were no health complications. The client is unaware of any other developmental delays.

Health History Client states that when he was a child he received all of the required vaccinations. He also reports having the chicken pox. The client also says he has an allergy to sulfa. He says when he was ten all the way until he was 18 he battled obesity. At age 18 he began loosing weight but is not near his overall goal of weighing 180 lbs. Other major health problems include a broken collarbone while skateboarding at age 13 and a broken foot due to dropping a weight on it at age 16. The client denies being on any medication or having any major diseases in his family.

Substance Use/Abuse History The client states that he uses marijuana almost every day. He says it helps him relieve stress. He first started when he was 16. He adds that he didnt start using it on a regular basis until he was around 20 or 21 years old. In addition, John also states that he drinks alcohol on average of three nights a week. The client also added that his mother used to smoke cigarettes around him when he was younger and he was exposed to a lot of second hand smoke. Mental Health History John states that he attended therapy when he was in the fourth grade. He says he only attended a couple of months worth of sessions before it was discontinued. He does

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not remember the specific issue that made his parents bring him, but he knows there were behavior issues at school. These issues mostly being conflicts, physical and verbal with his peers. Relationship/Sexual History The client states that as a child he never had many friends. He says that he now a has a handful of quality friends that he can trust and rely on. He has been friends with this group for around five years. The client states he first began dating in the 7th grade. He says he never experienced a meaningful relationship until he had his first sexual experience at 15. He states he has always been capable of achieving orgasm. The client is currently sexually involved with a female. The client considers this relationship to be a semi-committed relationship. The client says he practices safe sex the majority of the time, but finds himself having unprotected sex 3-5 times a month. The client has had two different partners within the past year. Family of Creation History The client is a member of a closely knit group of friends he would consider his family of creation. He is sexually and emotionally involved with a girl but does not consider it to be a committed relationship. Client spoke of having a couple of long term relationships since he has started dating and says he ended all of them due to their of lack of communication. At 22, the client and his most recent ex girlfriend had an accidental pregnancy near the end of their relationship. The pregnancy ended in a miscarriage.

Military History Client denies any military history.

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Financial History The client says he was raised in a financially stable home. He says he has never been aware of any financial struggles. His current financial state is solid. Because he lives with his parents, he is able to save his money from work.

Religious History The client says he was raised in a Catholic household. As a child, he attended church weekly. Once he turned 16 and got a weekend job he was unable to regularly attend mass. The client says when he turned 20 he began questioning Catholicism. He now considers himself to be a Nondenominational Christian. He does not regularly attend church and does not consider himself to be an extremely religious person.

Educational History The client considers himself to be of average intelligence. Says throughout grade school he received average to below average grades and never applied himself to his full potential. After graduating high school and taking a couple years off of school, he is enrolled in community college classes. He is doing well but is still undecided on a major.

Employment History When younger, John says that he was responsible for keeping his room and some of the house clean. His mother was in charge of making sure he had done so. He was also

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responsible for helping his father with lawn work on the weekends. At 16, he got his first job working stock at Kmart. Two years later he left Kmart and got a job at Wal-Mart because they offered better hours. John says he was not too fond of those jobs but at the time he thought he didnt have many options. At 21, John got a new job at a bank. John says he makes decent money but not enough to completely support himself to his desire.

Strengths I believe that this client has many strengths. The client described what sounds as a strong family network and quality friendships. He made it sound like those were some people he could really rely on. The client also identified that he is financially stable and has a good place to live that is rent free.

Prioritize Problems The client believes his depression may be the result of his inability to acquire a job that he both enjoys and will financially support him living on his own. The client believes other factors contributing to his depression may include his use of alcohol and drugs and his problems in his love life. When asked, John prioritized his problems in the following order: 1.) Job 2.) love life 3.) Drinking.

Translate Problems Into Needs Johns problems can be identified as needs. John does not have a job that will support him living independently. Therefore john has decided he needs to acquire a job which will provide him with the financial means to do so. Johns second priority is to focus on the problems in his love life. He believes he needs to eliminate promiscuous

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sexual interaction in his life and work on commitment. Lastly, his third priority is focused on his drinking. The client says he needs to stop dinking.

Evaluate Levels of Intervention Johns first priority is to obtain a job in which he enjoys and can support him financially living on his own. To obtain this John can look on the internet and in the newspaper to find jobs he already qualifies for that he may be interested in. He may also seek some career guidance at the community college he attends. Johns second priority is to focus on bettering his love life. Some levels of intervention would be for him to discontinue engagement in promiscuous sexual contact. He may also discuss the current state of his relationship with the girl he has become emotionally involved with to decide what his best option is. As for his third priority, John believes it is best if he discontinues drinking. Some options for john are for him to stop drinking and begin attending a support group for alcohol.

Goal Setting I. To obtain a job he enjoys and will financially support him living on his own. A. Search for a higher paying job he enjoys 1. Search newspapers and the internet for job listings in two weeks. 2. Create and submit a resume to potential jobs within those two weeks. 3. Follow up on all applications within a week of submission. B. Find a career path that follows his interest 1. Schedule a meeting to see someone in regards to career counseling at the

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community college he attends within one week. 2. Create a list of at least three potential careers of interest 3. Further explore this list of careers and decide what would be right and wrong for you. II. To increase the quality of his love life and clarify the status of his current

relationship. A. Discontinue promiscuous sexual activity immediately 1. Discuss with current sexual partners reason for discontinued activity 2. Discontinue contact with partners. B. involvement. 1. John will speak with the woman he is emotionally involved with about the state of their current relationship. 2. Decide whether he will continue on with the relationship or discontinue involvement. Establish mutual understanding of the status of current emotional

III.

Discontinue use of alcohol A. Seek support of friends and family 1. John will discuss with friends and family his issues with alcohol 2. Find an alcohol support group in the community he lives in within a

week 3. Attend a meeting within two weeks. B. Seek a therapist to discuss drinking problem

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1. Find a therapist that accepts his insurance within a week 2. Contact that therapist and schedule a meeting within two weeks 3. Attend therapy session within three weeks