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Complete an annual update: Please use the individual you paired up with for the initial intake assessment for the annual update. Depending on your agency this can be done yearly (annual) or bi-yearly which would be at a higher level of care (ACT Team). You may use an annual update from an agency (please approve it with me) the annual update can contain the components form (P. 460-467) Please include a service plan located on ( P. 480-481).
In your annual update obtain the client’s presenting problem (has it changed?) Is the client making progress? What are the client’s strengths? Does the client have any new medical conditions/ medications? Is the client using street drugs? What stage of change is the client in? What is the client’s culture what holidays do they celebrate? Include a social history as well. Include the client’s demographics. Include if they are on court ordered treatment. What is the client’s current level of functioning? What are your recommendations? We will discuss more in class the components needed in this assignment. 
Initial Assessment
Today’s Date: March 22, 2024
Patient First Name: Emily
Patient Last Name: Tochilla
Communication Needs (e.g., language): English
1. PRESENTING CONCERNS:1. What are you seeking help for today?: Emily seeks therapy to manage her anxiety and depression issues.2. On a scale of 0 to 10, with 10 being the highest degree of discomfort, how would you rate your concern when it first occurred?: 83. How would you rate your concern today?: 64. What is the first thing you did to start to reduce the discomfort?: I began journaling and exercising mindfulness practices.5. Behavioral Health Treatment History: Emily had previously attended outpatient treatment sessions, which have helped her manage her problems.6. What, or who has been most helpful in addressing your behavioral health symptoms? Explain: Prior outpatient therapy sessions were the most beneficial, equipping her with techniques for coping.7. What has been least helpful in addressing your behavioral health symptoms? Explain: Emily discovered that managing her issues only with medicine was ineffective.8. Are you concerned about your safety or the safety of your child?: No1. MEDICAL HISTORY1. Hospitalizations (how many and explain type)?: None2. Surgeries?: None3. Drug Allergies?: No4. Hepatitis B Vaccine?: Yes5. Any Chronic Illnesses?: None6. Do you use tobacco?: No7. Current Medications (frequency and dosage): None8. Medical Conditions: None1. NUTRITIONAL HISTORY1. Unexplained weight gain in the past three months (10 lbs or more)?: No2. Unexplained weight loss in the past three months (10 lbs or more)?: No3. Eating habits that you are concerned about?: No4. Dental Problems?: No5. Significant changes in appetite?: No6. Limited foods that your child will eat?: N/A7. Eats vegetables?: Yes8. Eats fruits?: Yes9. Special diet? If yes, name the diet and reason for it in the box below.: No10. Takes vitamins or supplements?: No11. Allergic or sensitive to any foods?: No12. Eats on a regular schedule?: Yes13. Issues relating to your eating or digestion, including bowel movements?: No14. Any other issues related to nutrition?: No15. Participation in sports or extracurricular activities?: None1. SOCIAL HISTORY1. How many people live in your home? Adults: Children: Emily lives alone.2. Do you participate in regular exercise?: Yes, Emily partakes in daily yoga.3. Do your child drink caffeine?: N/A4. Do you smoke?: No5. What is your water source?: Tap water6. Are guns kept in your home?: No7. Any issues we should be aware of?: No1. EDUCATIONAL/ VOCATIONAL
Emily is not presently enrolled in any educational or occupational training program.
1. Complete Educational information below:• Highest level of Education: Bachelor’s Degree• Do you have Copy of IEP (if yes, request copy from guardian): No• Do you have Copy of 504(if yes request copy from guardian): No• Special Education? (if yes please explain): No• Academic Performance: Good grades were earned.1. Initial SNCD:
Emily has positive ties with her family and friends. She is encouraged and cherished by them.
1. In general, how do you get along with others?: Emily gets along with people and loves socializing.2. Adverse Childhood Experience (ACE) Questionnaire Finding your ACE Score: Emily’s ACE Score is 1.1. SOCIAL DETERMINANTS OF HEALTH1. Do you have any financial concerns?: No2. Education: No3. Do you speak a language other than English at home?: No4. Do you want help with school or training? (getting a diploma or GED, starting a new job): N/A5. Do you or your guardian want help finding or keeping work?: N/A6. What is your housing situation today?: Emily lives in an apartment.7. Socioeconomic Status: Middle class8. Within the past 12 months, you worried that your food would run out before you got money to buy more.: No9. Within the past 12 months, the food you bought just did not last and you did not have money to get more.: No10. In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?: No11. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?: No12. If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc., do you get the help you need?: N/A13. How often do you feel lonely or isolated from those around you?: Rarely
Risk Assessment:
1. Have you ever thought about killing yourself?: No2. Are you currently having any thoughts of killing yourself? If yes, do you have a plan and means?: No3. Have ever attempted suicide?: No4. Have you ever thought about harming someone else?: No5. Have you ever harmed/injured someone else intentionally?: No6. Indicate which of the following risk factors apply: None
CRAFFT Screening:
Part A
1. Have you ever engaged in the use of synthetic substances?: No2. Do you use tobacco?:  No3. During the PAST 12 MONTHS, did you:• Drink any alcohol (more than a few sips)? Yes• Smoke any marijuana or hashish?: No• Use anything else to get high? (‘anything else’ includes illegal drugs, over the counter and prescription drugs, and things that you sniff or huff): No• Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs?: No1. LEGAL HISTORY1. Do you have any legal concerns?: No2. Is there current DCS involvement?: No1. MENTAL STATUS1. Mental Status Oriented: Place: _____ Time: _____. Situation: _____.2. Appearance: Casual attire, groomed.3. Level of Consciousness: Attentive and oriented.4. Eye Contact: Sustained throughout the session.5. Concentration: Capable of maintaining focus during a conversation.6. Motor activity: Normal.7. Speech: Clear and rational.8. Memory (Asked to repeat three words: Robin, Blue, and St. Louis.): Able to recite all three words correctly.9. Affect (as observed by the evaluator): Appears nervous.10. Mood (as reported by the individual): Depressed.11. Thought Content: Negative cognitive patterns were discovered.12. Thought Processes: Linear and coherent.13. Delusions: None reported.14. Perception (as observed by the evaluator i.e. responding to unseen others): No perceptual impairments were found.15. Impulse Control: Displays sufficient behavioral control at the session.16. Insight: Inadequate understanding of how her beliefs and activities affect her mental health.17. Estimated intelligence: Average.18. Psychosocial and environmental factors: Emily cites persistent difficulties from job and home dynamics. She senses an absence of social support.19. Problems with / related to: Emily considers primary support group and family concerns to be substantial pressures. She also discusses some educational problems.20. Significant recent losses: Emily describes the recent passing of a close family member, which has added to her current sadness.21. Protective Factors: Emily views her close bond with her sister and participation in treatments as protective factors.22. If individual endorses DTO/ DTS crisis plan required (Yes/No): No
Clinical Formulation Summary: Emily has signs of despair and anxiety, which have most likely been aggravated by current life stressors. Treatment strategies should center on cognitive behavioral therapies that tackle adverse behaviors and improve coping abilities. Furthermore, identifying social support systems and dealing with psychosocial stressors will be critical in her recovery. It is advisable to check indicators on a regular basis and analyze risks. Referral to continued therapy and possible drug assessment may help with symptom control.