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The client is a 46-year-old divorced male reporting two years of worsening depressive symptoms including irritability, anger, hopelessness, insomnia, and appetite loss, with passive SI and no HI. History includes anxiety and depression, prior intentional overdose, and alcohol misuse with recent blackouts. Treatment recommendations include weekly individual therapy, safety monitoring for SI, and reengagement with SMART recovery, coordinating care with PCP and a new psychiatrist.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":20,"@type":76,"position":81},"https://docshare.wps.com/document/exam/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/initial-assessment-intake-and-clinical-summary/329380/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/initial-assessment-intake-and-clinical-summary/329380.png","ImageObject",300,407,{"name":92,"@type":93},"Mary Man","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-03","2026-09-21",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What are the client’s main presenting symptoms during this assessment?","Question",{"text":112,"@type":113},"The client reports increasing depressive symptoms such as irritability, anger, hopelessness, insomnia, and loss of appetite over the past two years, affecting relationships. During assessment, mood is depressed and irritable with passive SI and no intent.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What is the client’s history of trauma and related systems involvement?",{"text":117,"@type":113},"The client reports parents divorced during high school, with frequent fights and occasional physical conflict prior to the divorce. The client recalls hiding in a closet during parental discord and reports no CWS involvement.",{"name":119,"@type":110,"acceptedAnswer":120},"How do the assessment findings guide treatment recommendations and safety planning?",{"text":121,"@type":113},"The assessment recommends weekly individual therapy to develop healthy coping strategies, reduce substance use and depressive symptoms, and closely monitor SI. The client agreed to reengage with SMART recovery, while the provider coordinates care with the PCP and new psychiatrist and maintains a safety plan.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},329380,1790566782,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":19,"category_name":20,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24,"preview_page_count":4},7421720224475,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Initial Assessment  \n\n| Client Information |  |\n| --- | --- |\n| Client Name:\u003Cbr>Last, First | Date of Assessment:\u003Cbr>7/17/21 |\n| Date of Birth: 2/19/76 | Referral Source:\u003Cbr>Primary Care Physician |\n| CPT Code/Time Spent:\u003Cbr>90791-50 mins | Other Agencies Involved:\u003Cbr>SMART recovery |\n| Source of Information:\u003Cbr>Client | Preferred Language of Treatment:\u003Cbr>English |\n| Beneficiary Rights |  |\n| Beneficiary Rights Provided:\u003Cbr>☒ Explanation of the State Guide to Medi-Cal Mental Health Services\u003Cbr>☒ Grievance/Appeal Process\u003Cbr>☒ Notice of Privacy Practices\u003Cbr>☐ Not provided, Explain: |  |\n| Domain 1: Presenting Problem/Chief Complaint (Presenting problem, current mental status exam, impairments in functioning): |  |\n| Client is a 46-year-old, Caucasian, divorced, heterosexual male with depressive symptoms. Client recently finalized divorce with his wife of 9 years, which he reports has increased depressive symptoms of irritability, anger, hopelessness, insomnia, and loss of appetite. Client reports he has been having an increase of these symptoms for the past 2 years. Client states his depression has impacted his relationships with family and friends. During assessment, client presented with casual dress and disheveled appearance. Attitude was calm and cooperative. Poor eye contact , no abnormal movements or psychomotor agitation. Slow speech with low volume. Depressed and irritable mood. Linear thought process, no AH/VH/delusions reported. Passive SI with no intent. No HI. Client presented as drowsy, oriented x4, difficulty concentrating and was a fair historian. Fair insight and judgement. |  |\n| Domain 2: Experience of Trauma (Trauma exposures, trauma reactions, trauma screening, systems involvement): |  |\n| Client’s parents divorced when client was in high school. Client reported that, prior to the divorce, his parents would often fight and at times become physical. Client recalls having to hide in the closet with his brother during the parental discord. Client reported no CWS involvement. |  |\n| Domain 3: Behavioral Health History (Mental health history, substance abuse/use, including past and/or present nicotine use, previous services, interventions that have been utilized): |  |\n| Client’s diagnostic history began at 19 years old, to include Anxiety and Depression. Client has received therapeutic services intermittently since then. Client reports better outcomes with male clinicians, as he feels more comfortable with them. Client had one hospitalization in college for SA in which he intentionally overdosed on 36 OTC medications. Client reports he experimented with various substances in college and drank alcohol 5-6 days a week to the point of becoming inebriated. While intoxicated, client engaged in verbal and physical altercations with strangers, which resulted in two arrests in the past (no current charges) and minor injuries. Alcohol abuse also impacts client’s timeliness, productivity, and relationships with coworkers at work, resulting in many warnings and potential for losing his job. No tobacco/nicotine use reported. Client states he used to attend SMART recovery but has since relapsed and disengaged from services. |  |\n| Domain 4: Medical History and Medications (Physical health conditions, medications, developmental history): |  |\n| Client currently taking HCTZ, ZOCOR, and Effexor 75 mg BID. Client reports hypertension and high cholesterol. Both managed with medication. |  |\n| Allergies: No food or drug allergies reported |  |\n| Primary Care Physician: Dr. Primary 888-555-4567 |  |\n\n\n| Domain 5: Psychosocial Factors (Family history, current family involvement, significant life events within family, social and life circumstances, social supports, legal/justice involvement, community engagement, cultural considerations): |  |\n| --- | --- |\n| Client has a history of arrest due to assault while under the influence. He reported minor offense as a juvenile for shoplifting. No current legal involvement. Client works part","cbCaidUsvvtVxMEO","https://ap.wps.com/l/cbCaidUsvvtVxMEO","pdf",100145,"English","# Client Information\n# Domain 1: Presenting Problem/Chief Complaint\n# Domain 2: Experience of Trauma\n# Domain 3: Behavioral Health History\n# Domain 4: Medical History and Medications\n# Domain 5: Psychosocial Factors\n# Domain 6: Strengths, Risk and Protective Factors\n# Domain 7: Clinical Summary, Treatment Recommendations, Level of Care Determination","[{\"question\":\"What are the client’s main presenting symptoms during this assessment?\",\"answer\":\"The client reports increasing depressive symptoms such as irritability, anger, hopelessness, insomnia, and loss of appetite over the past two years, affecting relationships. During assessment, mood is depressed and irritable with passive SI and no intent.\"},{\"question\":\"What is the client’s history of trauma and related systems involvement?\",\"answer\":\"The client reports parents divorced during high school, with frequent fights and occasional physical conflict prior to the divorce. The client recalls hiding in a closet during parental discord and reports no CWS involvement.\"},{\"question\":\"How do the assessment findings guide treatment recommendations and safety planning?\",\"answer\":\"The assessment recommends weekly individual therapy to develop healthy coping strategies, reduce substance use and depressive symptoms, and closely monitor SI. The client agreed to reengage with SMART recovery, while the provider coordinates care with the PCP and new psychiatrist and maintains a safety plan.\"}]","Initial Assessment - Intake and Clinical Summary | PDF",1789983954]