Assessment and Treatment Plan

Confidential Bio/Psycho/Social Assessment

Name:Address:

Date of Birth:Phone:

Primary Language:Education:

Referred By:Occupation:

Assessment Evaluated By:

Description of Client

The client is a 30-year-old female, dressed casually in neat, clean clothing. She makes normal eye contact, speaks in an expressive voice, and appears ill at ease, manifested by nervous hand movements and foot jiggling.

Presenting Problem

The client reports that she feels anxiety about her job. The symptoms of anxiety in her life are diminishing the enjoyments that she had in her life. The same situation has been persisting for the past year. Situation worsened during the past six months.

History of Problem

For the past ten years, the client has been working as a long distance operator. She states that the work that she does is enjoyable, however, she faces extreme stress with each passing year. The company she has been working in has increased its layoffs. She was protected due to her seniority. However, the longer term employees have been affected. She has only small savings and has credit card debts. She is fearful that she will be laid off and will not be able to get a job that pays as well because she has never done anything but work as an operator. Prior to 6 months ago, she reports occasional anxiety around specific events, such as a test at school or a problem with a boyfriend, but none to the extent that she has experienced in the past 6 months.

Mental Status

Cognitions

The client is oriented to person, place, and time. She speaks precisely and her thinking appears to be clear and goal-directed. She reports that she is worried and goes over and over her fears about the layoffs at work.

Affect

The client's range of affect is somewhat limited and flat.

Mood

The client appears to be depressed.

Behaviors

She reports that she experiences ...