Sally Fitzgibbons Foundation

Beginning the Academic Essay

Name:David Robert Date: 30 October 2018 DOB: 1969
Age: 49 Start Time: ____________ End Time: _____
Identifying Information:
The client’s name is David Robert who is a 49-year-old male who has been married for 21 years and has two adult children. The client works as a metallurgical engineer in a local steel mill where he has worked for 20 years. His hobbies are reading, playing golf, and watching TV. David lives with his wife who was his high school sweetheart.
Presenting Problem:
David is not anymore interested in going to work but rather states that he would rather spent some days just staying at home. David reports feeling blue and his appetite has also decreased. He also reports losing interest in the things, which he used to like preferring to spend time alone in his bedroom. David also complains of irritability and low energy with experiences of physical pain in his back and neck area. David is resistant to going to see a doctor and believes his mood will eventually improve.

Life Stressors:
David feels that he is not worthy living and has tried to take certain measure to help him in addressing the issues that he is facing but nothing seems to work.

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Substance Use: FORMCHECKBOX Yes FORMCHECKBOX No
Due to the sleeping problems that David is having, he drinks more at night having started the drinking habit when he was younger. However, David has reduced the frequency of his drinking habit to two or three beers per night.
Addictions (i.e., gambling, pornography, video gaming)
None reported
Medical/Mental Health Hx/Hospitalizations:
None reported
Abuse/Trauma:
None reported
Social Relationships:
David does not have the desire to go to work anymore rather prefers just staying at home alone. David’s relationship with his wife is described as typical meaning that they do not spend much time together but only meet during meals and attending family gatherings. David prefers spending time alone in his bedroom.
Family Information:
David has a sister whose name is Lisa who had similar problems where she struggled with depression for over 10 years where she is currently receiving medical assistance from a psychiatrist and a counselor. Some of the symptoms, which Lisa had, include emotional and physical fatigue, low mood, increased weight gain, and sleeping problems. David’s oldest son is concerned about his father and feels that his father needs to go and see the doctor due to his unusual behavior.
Spiritual:
None reported
Suicidal:
None reported
Homicidal:
None reported
Assessment:
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Initial Diagnosis (DSM):
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Initial Treatment Goals:
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Plan:
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Name: _____________________________________________ Date: __________________

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