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Pamela is a 29 y/o married female mother of 2 (one with development disorder). She has been married 10 yr. ??" there has been some conflict in the marriage. Over the past year they have been separated but they have now decided to get back together. She works for bio-father as a part time book keeper. She lives in Colorado Springs with her children and her husband.
She indicated that her mother and father were both married "8 or 9 times each" throughout her life. She was raised by her mother who had several abusive stepfathers. She did not see her bio-father much at all until she was an adult. He had a whole other family. She reports neglect from her mother growing up due to mom’s alcohol use. Her grandmother would have to intervene at times because there would be no food in the house. She reports that her mother, uncle and older sister are all diagnosed with bipolar.
She dropped out of school in 9th grade due to pregnancy. She had an abortion but her step father wouldn't let her go back to school because "everyone knew about it". She does have a GED. She indicated she did well in school from 1st-8th grade. For the past 10 years she has worked part time as a housecleaner and part time book keeper. She is presently working for her father.
She has been married since 19 to a man 4 years older than her. She states that he is controlling. They have two children together, one is a 7 year old who is autistic, and a 9 old.
She has been dealing with many stressors for the past year. Her husband went to jail for stealing for a few months this past spring. While her husband was in jail she became involved with a male who was a friend of her friend. She realizes that this was an affair. Her husband found out. She states that while she was with this person she was happy. She suspects all of her problems circle around her relationship with her husband. She thinks she needs to at least work on this relationship given their time together and the two children.
Carl was born in Pennsylvania but his parents moved to Florida when he was still a baby. He grew up in Clear Water Florida. In his childhood his mother went to prison for drug related charges and he lived with his aunt. He expressed being close to his aunt and lived at both his aunts and with his mother home when she came out of prison. He does not recall much about his father or any other male figure in his life. He moved to Colorado Springs when he was 20 - his mother and aunt still live in Florida.
He indicated he has learning difficulties and had trouble with school ??" he dropped out after 10th grade. He does have a GED. He went into construction. He worked for someone else for a time while in Florida and when he moved to Colorado he opened his own business. His business eventually failed due to financial problems and he started to work for his present wife’s father.
He was caught stealing equipment from a construction site in the winter and spent time in Jail in the spring due to this. He is now out of jail but not at home. He wants to get back together with his wife.
Both of them met in Colorado Springs and despite the difficulties over the past year both indicate they wish to work out the marriage.
Include the purpose and key elements of each part of the working agreement:
• Statements of confidentiality and informed consent
• Roles, expectations, and responsibilities of all parties
• Intervention methods used to attain goals
• Frequency, duration, length, and location of the meetings
• Means of evaluation or measuring progress toward goal attainment
• How the working agreement can be renegotiated
• Consequences of either party not upholding the agreement and how unforeseen complications will be handled
Use the following resources as references
Outline for Assessment
Identifying and demographic information
Name, age, gender
Cultural or racial identities
Employment, education, training
Economic status, including problems or needs
Presenting problem or concern
Strengths and resources
Social supports, including friends, cultural, and community networks
Cultural and spiritual beliefs and practices
Motivation and readiness for change
Significant developmental events
Effects of race, culture, sexual orientation, age, class, immigration, and other influences
Current or continuing
Cognitive or intellectual capacity and skills
Emotional/affective state and self-regulation
Health and biological factors
Substance use, abuse, and dependence
Wellness activities (exercise, yoga, meditation, etc.)
DSM IV-TR diagnosis (all five axes)
Formulation or conceptualization
Axis I: Clinical Syndromes and Other Conditions That May Be a Focus of Clinical Attention??"includes all diagnoses (except those listed in Axis II) or other conditions such as academic problems
Axis II: Personality Disorders or Mental Retardation??"chronic long-term conditions
Axis III: General Medical Conditions??"that are important to understanding the diagnosis and treatment or that may have a role in causing the disorder
Axis IV: Psychosocial and Environmental Problems??"problems that may affect diagnosis and treatment
Axis V: Global Assessment of Functioning??"rating on a scale of 1??"100 of how well the person is currently functioning and may also include the highest level of functioning during the past year.
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