INTAKE DATE: Mar xxxx

DEMOGRAPHIC DATA:

This is a voluntary intake for this 33-year-old Hispanic female. Sofia has been married for 9 years and has been having challenges with her wife for the past four months. Sofia and her wife have one daughter and two sons. Sofia is employed as a car sales manager and is very successful at her career.

CHIEF COMPLAINT:

"My wife insisted I seek treatment due to my behavior. I do not want to lose my family. My wife said if I attend treatment we can stay together."

HISTORY OF ILLNESS:

Sofia reports having one past psychiatric incident. At twenty-seven-years-old Sofia attempted suicide after her wife of three years left her. She was hospitalized in a psychiatric unit for three days. Sofia showed signs of feeling down, fearful, and suicidal. Her wife indicated she would become very agitated and would sometimes punch the wall. She feared she would be the victim of some of her acting out. For a few weeks, Sofia would not get out of bed or go to work because she said she could not concentrate on work, she was feeling so bad.

She sought treatment now by the encouragement of her wife since Mrs. Sofia described Sofia as strange lately. Sofia always embraced life and goes through periods of being “on top of the world”. Sofia reports she is very generous with her family and buys a lot of gifts, which everyone appreciates, even though her wife sometimes complains about it. “It’s not like I can’t afford it” Sofia states. Her wife indicates that something is different over the past couple of months but cannot really put her finger on it. More recently Sofia has days which she is more talkative than in the past and wants the entire family to have “family discussion” time. Mrs. Sofia and the children could not get a word in edgewise though. Mrs. Sofia worries that Sofia may be using some kind of drug periodically especially when Sofia is up most of the night. She needs to sleep to get to work but a few hours of sleep does not seem to affect her. Her work is not affected by this behavior. This behavior seems to settle down after a few days. When asked, it was reported that it does not even last a week but has been coming back.

PSYCHOSOCIAL HISTORY:

She is employed at a car dealership and started off washing cars. Her focus was on advancing her career and she believed she could get into management in a short period of time.

Sofia grew up in an average household with both parents working in a factory. Her dad was eventually promoted to foreman. Mom and Dad would have different shifts so it was rare that they would have dinner together. Sofia has nice memories about Sundays since the family would go to church and have a nice dinner. Many of the relatives would gather each week at a different house. Sofia has 6 siblings. Sofia was initially considered an underachiever in the early years of school. She chose not to attend college because she wanted to get out in the work force for money.

SUBSTANCE USE HISTORY:

Sofia indicates she is a social drinker. Through collaborative contact from her wife, she confirms Sofia is a social drinker. Mrs. Sofia believed Sofia might be taking something else once in a while since Sofia’s behavior is very different than her normal behavior sometimes.

MEDICAL HISTORY:

Sofia has no significant medical history. She has had the normal childhood illnesses. With extensive toxicology there was no evidence of drugs or alcohol in Sofia’s system.

FAMILY ISSUES AND DYNAMICS:

Sofia is currently married with three children, one daughter and two sons. This is her only marriage. Through collaborative discussion with her wife, she indicates Sofia is a great provider and keeps the family financially stable. There was that one incident when she was hospitalized but overall their relationship has been good.

More recently, Sofia has been feeling really good “on top of the world.” This feeling lasts a few days. She then would have angry outbursts and act out and punch the wall. Mrs. Sofia believed this was due to her lack of sleep. She said she was not tired, and she noticed Sofia would play video games most of the night, then go to work in the morning with no difficulty. Mrs. Sofia worries about their financial state because Sofia would be buying big items but there is no evidence of financial difficulty.

MENTAL STATUS EXAM:

Sofia presents as a neatly dressed female who appears younger than her stated age. Her nails are neatly groomed. Facial expressions are appropriate to thought content. Motor activity is appropriate. Thoughts are logical and organized. There is no evidence of hallucinations. Sofia admitted to a history of suicidal ideation years ago. Her mood is up and excited. During the interview, Sofia talked fast. She indicated this is because she feels tense but this is not unusual for her. Sofia reports she is concerned about her concentration since she is so worried about her wife leaving with the children. Sofia cannot understand what is wrong. Sofia is oriented to time, place, and person. Her intelligence appears above average.