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Running head: PART A.



Kelly Talbert
Wayne State University
SW 3020
Professor Schropshire
July 13, 2014
Demographic Information

Date of Birth: 06/21/84

Name: Anastasia Kirvoch

Age: 30

Address: 12345 One St.

Sex: Female

Detroit, MI 48204

Phone: 313-123-4567

Ethniticity: African American

E-mail: AKirvoch@sbcglobal.net

Date of Interview: 7/13/14

Intake Clinician: Kelly Talbert

Anastasia Kirvoch is a thirty year old African-American female who is currently
separated from her husband Roman Kirvoch as a result of a marital affair and a child born as a
product of this affair. Mrs. Kirvoch resides in the marital home with her two children (twin
females 5 years) Anastasia has been a stay at home mom for five years, she is in danger of losing
the home if her husband does not start to make the payments on the mortgage. Mrs. Kirvoch was
referred for a social work assessment as a result of stress, and depression over her separation
from her husband and the slow process of the courts for a divorce, alimony, and child support.
Family of Origin History:
Anna Kirvochs parents ages at birth were, father Ralph (27), and mother Abagail (25).
Mrs. Kirvoch parents were married; she has an older brother Adolphus (33), he is single; both
Anastasia and Adolphus were planned. The clients childhood was loved and privileged; all
holidays, were celebrated, their favorite holidays are Easter, Christmas, New Years and all family
reunions. Parents and siblings have earned college degrees. Parents and siblings are all healthy.
The grandfather died of natural causes at age of eighty-three. Anastasias grandparents were
raised in poverty in the south, they met and married in 1949 and the maternal great- grandfather
brought them to the north for better opportunities of employment. Mrs. Kirvochs greatgrandfather was hired at Ford Motor Company at the age of 21.
Developmental History
Client was full term pregnancy; weight 6lbs/8oz. No significant issues at birth; vaginal
delivery; breastfeed for three months, then bottle fed. The client reported advanced
developmental early in walking, talking, and potty training by age two.
Educational History
The client began Catholic Montessori School at the age of two and half.
Health History
Mrs. Kirvoch was reportedly healthy at birth; childhood illness included Chicken Pox,
and Measles. Client reported one car accident as passenger in 2013; with no significant injuries
requiring hospitalization. In 2010, Mrs. Kirvoch; reported Hiatal Hernia Repair surgery; Mrs.


Kirvoch reported no significant family illnesses. Her first menses was at the age of thirteen. Mrs.
Kirvoch was prescribed Zantac 10 mg. and Bentyl 20 mg. for acid reflux, and irritable bowel
syndrome. Client denied allergies to any foods or medications.
Relationship/Sexual History
Mrs. Kirvoch reportedly has one best friend Savvy and a host of friendships from
childhood with the exception of the one made at college. Client began dating at sixteen years old;
her sexual orientation is heterosexual; Mrs. Kirvoch was eighteen when she experienced her first
sexual experience. Mrs. Kirvoch reported enjoying sexual encounters with multiple having
sexual orgasms; she denied actively having sex or dating at this time. The client does not take
any birth control. Due to the circumstances of her marital separation, the client received a
sexually transmitted exam and reported negative results.
Family of Creation History:
Anastasia married at the age of twenty-three. Her children were planned; however giving
birth to twins was unexpected. Her daughters are five years old, Alexandria and Andrea. The
client reported currently separated from her husband with a pending divorce; however both
parents are active in the twins life. Both parents have earned college degrees: Anastasia has her
Bachelor of Science in Nursing and Roman has earned his Master in Business of Administration,
he is currently employed at William Beaumont Hospital as an Executive Director of Finances.
Substance Use/ Abuse History:
Anastasia reports she began moderately drinking in college. The setting was the "party
life" for college with her peers, i.e. Frat parties, raves, etc. She denies that the partying affected
her academics and she denies putting herself in harms way as a result of her choice of substance
abuse. She denies any use of neither recreational drugs nor cigarettes. The client reports that she
fears she may be drinking too much wine. Anastasia is "drinking" a bottle 750 ml. of Pinot
Grigio every night.
Mental Health History:
The client reports feeling of depression due to the circumstances of her current situation.
However, she has not received a formal mental health diagnosis.
Military History:
The client denied military experience.
Financial History:
Client reported family finances while growing up were high middle class. Finances currently
for her are not great, because Roman is not being cooperative, his finances are presently great,
and he is in the white collar level.
Legal History:


The client is currently involved in a divorce and separation.

Immigrant Issues:
The client denied any immigration, however it is documented that the clients estranged
husband was an exchange student from Russia. Roman successfully completed his education and
residency requirements to stay in the United States legally and without limitations. Client denies
marrying for immigration reasons.

Part B. Plan of Change

Kelly Talbert
Wayne State University
SW 3020

Professor Schropshire
July 27, 2014
Part B. Plan of Change
Description of the Problem:
Mrs. Kirvoch is currently separated and in the middle of a divorce from her husband
Roman as a result of an affair. She resides in the marital home. She is at risk of losing the home,
if Roman does not cooperate with the court appointed orders of support. However, as a result of


these issues Anastasia has become stressed and is suffering from signs of depression. Anastasia
has also begun to drink heavily, a bottle 750 ml of wine - Pinot Grigio every night.
Considering the problems Mrs. Kirvoch would like to proceed with finding ways to reduce or
stop drinking and reduce or eliminate feelings of depression.

Goal number one is to design a way to deal with her feelings of stress and
A. Objective number one is to individual counseling, once a week for an hour with a
Social Worker for six months.
1. Task number one is for the Mrs. Kirvoch to attend her regularly scheduled
appointments with the social worker.
2. Task number two, Mrs. Kirvoch will keep a journal of all feelings, good, bad,
or indifferent and discuss those feelings at her appointments.
B. Objective number two is to refer Mrs. Kirvoch for formal psychiatric evaluation.
1. Task number one, Mrs. Kirvoch is to obtain an appointment for evaluation.
2. Task number two is for Mrs. Kirvoch to confirm a diagnosis conclusively, if
she has depression so she can receive the proper medications, or ruled out.

II. Goal number two is for Mrs. Kirvoch to deal with her substance abuse issue.
A. Objective number is to acknowledge that Mrs. Kirvoch does indeed have a
substance abuse problem with alcohol.
1. Task number one is to discuss why she is drinking wine heavily.
2. Task number two, Mrs. Kirvoch will immediately join a group therapy session
for Alcohol Anonymous.
B. Objective number two is for Mrs. Kirvoch to strive to become motivated with life.


1. Mrs. Kirvoch will purchase the book ," Don't Sweat The Small Stuff...And
It's All Small Stuff" by Richard Carlson, PH. D.
2. Mrs. Kirvoch will read this book.

Signature of Client


Signature of Worker


K. A. Talbert, interviewer. BIO-PSYCHO-SOCIAL ASSESSMENT. July 13, 2014