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Biopsychosocial

Identifying information
This clinician assessed a 25-year-old female who prefers to be addressed as she/her. She is black
of African descent and is originally from Jamaica. The client is a college student who is
attending Parkland College and is in her second year in college. She works as a part-time
bilingual secretary at an elementary school in Champaign. She is single, has no kids, and is
planning on getting married soon. Client has no direct family in the USA and lives in an
apartment with three roommates.

Initial Presentation
Client appeared to be mentally stable. Even though it was a video meeting, the client’s
appearance was good. She looked clean with neat clothes and hair; no jewelry and make up as
she was just at home confined because of COVID-19. She is facing few challenges but nothing
major that could make her mentally unstable. She reported being stressed out, worried,
sometimes lacking concentration, and losing interest. Client’s thoughts were lined up and she
was able to answer all the questions. Her tone was consistent; her volume was normal; and her
rate and intonations were normal. She was cooperative and engaged into the conversation. She
did not pause between questions. She was calm throughout most of the session. However, she
was emotional while talking about challenges that she is facing in her life. Client was tearful
when she was describing her stressors. Client’s thoughts were intact as she paid attention to
questions and answered them accordingly. She was focused and concise. Client is having
financial hardship that is prohibiting her from transferring to a 4-year college. She stated that she
was an “international student and was unable to pay the tuition”. Now she “owes the college she
used to attend before Parkland College more than four thousand dollars. She needs to pay the full
amount before the school can allow her to get access to her transcript which she does not have at
this moment”. She is “stressed out, in lacking concentration, and worried” about what she will do
next as this is her last semester at Parkland College. He only option is “work unless god does a
miracle”. She has lost interested in many things that she used to like. Client was referred to this
clinician by her friend.
This problem has been going on for 2 years. The problem is severe as it now starting to stress
and worry the client and she is confined and does not see what the next step is going to be in her
life. Client is experiencing a barrier in her education, the only option she has is paying the money
she owes to that community college. However, client said that she is thankful for what she has
now.
Severity Scale on client’s lack of concentration
1. Tired all 2. Cannot 3. Unable 4. Warnings 5. Get fired
day remembe to from from
r where perform supervisor work
she put at work
things. or at
home

Brief History
Client’s family still lives in Jamaica. Client did not report any history of mental illness or major
medical concern in her nuclear family. However, in her extended family there is a history of
depression, cancer and diabetes. Client also reported being burned 5 years ago in her apartment
when the fire started with her old roommate cooking. Client stated that she does not know if one
of her direct members of the family has a mental illness because, culturally, they do not ask those
kinds of questions. Client has not been diagnosed with any mental or physical illness in her life.
Client has met all her milestones.

Current Functioning
Client reported to have a good support system and strengths including friends, church, prayer,
listen to music, doing exercise, and shopping. She is always looking at the bright side. Her
current stressors are financial hardship, transferring to a 4-year college, and being unable to see
her family especially during this COVID-19 period. She has lost interest in many things; she is
worried, stressed, and sometimes lacks concentration. Client has friends, church members, co-
workers with whom she gets along. Although she is not able to see her family face to face, she
can see and talk to them through video calls. Barriers and risks include the fact that she does not
know her next move, or when she would be able to get money to pay her debt to the community
college and be able to access her transcript. Client stated that she knows how important
education is in this country and is aware that she is unable to get a “decent job without a degree”.

Risk Assessment:
Client does not have a history of prior suicide attempts or self-injured behavior.
Client he has never seen a specialist for any mental disorder. Client did not report any family
history of suicide attempts or mental disorder (nuclear family). Client reported to be stressed out
sometimes but has coping mechanisms including praying, listening to music, shopping, and
exercising. Client reported to never have any suicidal ideation. So, this clinician thinks that the
risk level is low. Client was provided crisis emergency numbers.

Treatment plan
Hypothesis development
The root of all the client’s problems is the unsupportive behavior from his family back home. As
an international student, she was supposed to be receiving financial support from her family
because international students in the USA are not permitted to work and make enough money
that can cover the tuition. Client is worried and stressed out as she does not know how and when
she would be able to pay off this debt. She has also lost interest in things that she used to like and
is less focused. As this clinician was assessing the client, many questions were raised: why was
the family not sending any money to their child? Did they know what their child was facing as
challenges? Was there any change in the family financially speaking? What are the parents’
professions? Was there any other source of income? Is there any service or resources in the USA
that can help with this kind of problem? If she is earning minimum wage now, how long will it
take her to get enough money to pay her debts?
At a micro level, the problem might be occurring because of the financial issues. Client income
cannot pay the debt. At the mezzo level, Client’s family is unable to help her financially. Client
has not sought or found a support group that can help her financially. Client did not seek a
support group that can help with her stressors. At the macro level, client has not sought or found
an organization or a service in at the national or international level that can grant her some
money to cover her debts.
Establishing Goal
Behavioral goal: Client will find a source of income that can help pay the community college’s
debt. Client would monitor her stressors level everyday for the next six months.
1. Avoid negative expectations
2. Get enough sleep
3. Have a professional opinion on how to keep the stressors level down
Service goal: Find out where they are hiring.
1. Job fairs in the community
2. Online resources including Indeed Jobs, LinkedIn Job Search and others
3. Contact hiring companies directly.
The baseline for this client is to find a job that could pay her at least $15 an hour for her to be
able to get $4000 that she owes the community college in the next six months. Client must hold
the job for at least 6 months to allow herself to get enough money that would solve her problem.
Client should keep the job unless it is necessary to quit.
Service intervention Plan
At micro level, client would make minimum payment with the small income that the client
receives and change lifestyle by spending less and saving more. Client should also constantly
monitor her stressors. At the mezzo level, client would find local organization that can help with
the debt partially. Client would join support group or participate to a webinar that can teach the
client about money management and how to pay one’s debt. Even though it is not severe, client
should find a support group that can help her with her stressors
At the macro level, client would find organizations, aids, and scholarships that can help
international students pay tuition. Since her income is low, she can qualify for SNAP and
TANAF and save some of her income to pay her debt. Client would also find Free clinics in the
community that can help with therapy and counseling.

1 Immediate problem: financial (money) management


Client has financial problem and she is a student. So, social worker would refer her to Financial
Wellness for College Student. This is a University of Illinois extension that aims to help college
students (not just Illinois students) to learn to manage effectively their money and make wise
financial decision. Clinician chose this agency because all their services to students are free. The
client has been working part-time for more than a year now but did not put any minimum
payment toward her debt. So, she needs guidance on money management. Client is a student and
is unable to afford counseling service. With this service, she can meet with a counselor and learn
about money management and budgeting; she is able to sign up for monthly newsletter that can
help her with financial tips, and she can access webinars that can educate her on money
management. Plus, the service center is in the same town as the client.

Evaluation
Social worker would receive weekly report from the client about her financial situation and see if
client has been saving or making paying to the agency that she owes money. Social worker
would see if the client got the job for which she applied for extra income and monitor how well
she is doing at the new job. Social worker would also receive report on how the client is
managing her stressors and if the new job causing the her more stress. Social worker would also
see if client has been able to at least make plans to see her family again.

Termination
Service would be terminated f client was able to pay off his debt after a period of six months, or
at least a part of it and she is keeping on making payment; f client can manage her stressors
(emotional problems); and if she has mastered manage her money accordingly.

Follow up plan
Social worker would keep in touch with client, with her permission to check on her and follow
up monthly maybe; continue to informally assess her and see if she needs any help if she keeps
on paying the debts or she has finished it; check on her level of stress, worries and concentration;
if she is still socializing with her friends and co-workers; and finally, if she is till part of her
church.

Social worker’s impression and assessment.


Client sees financial and familial problems. She is worried and stressed out because of her
transcript that is retained at the community college where she owes money. Without her
transcript, she is unable to transfer to a 4-year university. She also is worried about her family
that she has not seen in a long time.
Social worker thinks that client see money management issue. On top of financial problem, client
is very worried about her financial and familial problem that she forgets to take care of her
mental health. She also does not know how to handle the income that she has. Client is worried
and stressed out about her situation. All her issues in making her lack concentration at many
things that she does, even though it has not ended up to a negative result. Client has not made
any effort yet to solve her problems. The first step is meeting with the social worker.

DSM 5 impressions
Differential diagnoses: depression. Depression was chosen as a differential diagnosis because the
client reported that she lost interest in many things that she used to enjoy. Plus, client’s extended
family has a history of depression. Another differential diagnosis might be PTSD because client
has never talked about the fire after the incident. She reported that every time she tells the story,
or she thinks about it, she feels like she is reliving the moment again.
Diagnosis/Comorbidity: Client has Anxiety symptoms. Client is experiencing stress, lack
concentration, and worries. Other symptoms of Anxiety like muscle tension, irritability, and
being tired all the time were mentioned by client.
Summary
Current issues are Financial and familial issues. Stressors experienced by client include Stress,
worries, loss of interest, lack of concentration Client’s strengths include church, praying, friends,
co-workers, talking to family via social media, listen to music, shopping, and exercising, looking
at the bright side. Initial steps towards a solution are Seeing social worker, finding another
source of income, and seeking emotional support. Client would make minimum payment and
constantly monitor her stressors. Client would find local organization that can help with the debt
partially and join support group to help with her stressors. client would find organizations, aids,
and scholarships that can help international students pay tuition and free clinics that could help
with her mental health.

Signature: Date: 05/03/ 2020

Name and credentials: Irene Ngoya, BSW

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