THINGS I WOULD RATHER FORGET IN TRIPLICATE

NAME: JUANA
AGE: 42
ETHNICITY: HISPANIC
PRESENTING PROBLEM: ANXIETY

AXIS I GENERALIZED ANXIETY
AXIS II DEFERRED
AXIS III CANCER SURVIVOR
AXIS IV HUSBANDS ALCOHOLISM, SON’S OUT OF CONTROL
AXIS V: 45/60

BRIEF SYNOPSIS: JAUNA CAME INTO THERAPY AFTER HER SON ATTEMPTED TO SCALP HER AND WAS HOSPITALIZED. HE IS NOW ON A 5250 HOLD AND THE HOSPITAL WOULD LIKE HIM TO RETURN HOME BY THE END OF THE WEEK.

RECOMMENDATION: ONGOING THERAPEUTIC SUPPORT FOR JAUNA AND HER FAMILY.

OBSERVATIONS: JUANA WAS AGITATED WITH PRESSURED SPEECH. SHE SMILED FREQUENTLY.