You will be using the template provided in the link below to write your assessme
You will be using the template provided in the link below to write your assessment. This template identifies assessment sections. Using the Maggie’s case and your text/supplemental materials, you will complete each section.
Please note, this is not a complete assessment. This assignment is intended to prepare you to start thinking about what is included in a full assessment. Write this as if it was going into Maggie’s health record. Use complete sentences and proper grammar.
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Maggie Weinzapfel
Identifying Information:
Client Name: Maggie Weinzapfel
Age: 26 years old
Ethnicity: Caucasian
Marital Status: Single
Intake Information:
Maggie, a 26-year-old Caucasian female, contacted the Family Guidance Center after breaking
up with her fiancé, whom she had been dating for the last 4 years. Maggie is a mechanical
engineer at a fiber optics corporation in a small Southern town. She makes a good salary, owns
her home, and recently bought a new car. Maggie moved from the large, metropolitan area in
the Northeast where she had met her boyfriend to this rather small Southern town
approximately 1 year ago when she procured her present job. Her parents and siblings also live
in the Northeast. Maggie has two sisters, both in their 20s, and two teenage brothers who still
live with their parents. When Maggie called the clinic, she stated that she desperately needed
to talk with someone as soon as possible. The intake worker wrote in her notes that the client
“sounded panicky” when making an appointment to see a counselor. You are scheduled to see
Maggie the day after she called
Intake Interview:
You meet Maggie in the waiting room at the agency. Maggie appears very disheveled. Her
baggy pants and sweatshirt are wrinkled, and it looks as if she forgot to brush her long, wavy
hair. She is pacing slowly back and forth and appears to be staring at her feet. She runs her
hands through her hair continuously and looks generally distressed. Every now and then, she
sighs deeply and shakes her head as if responding to some internal dialogue. You greet Maggie
in the waiting room by introducing yourself and shaking her hand, which feels sweaty and limp.
As you and Maggie walk down the hall to your office, Maggie bursts into tears and says, “Oh,
I’m so embarrassed; I don’t know what I’m doing here.” As you and Maggie enter your office,
you reassure Maggie that it’s safe for her to express her feelings with you, offer her a chair, and
provide her with a box of tissues. You begin by gently asking Maggie where she would like to
start. Maggie states that she broke off her engagement with her boyfriend, Leonardo,
approximately 6 weeks ago. She says they had been arguing constantly for the past 6 months
about where they were going to live. She wanted to keep her job and live in a small town, but
he wanted to live in a large city and didn’t want to leave his fam- ily in the North. He told her
that Italian families are very close: “We stick together and want to see each other. I grew up in
this city; I’ve been to the same church my whole life; and I intend to die in this city. If you’re
going to be my wife, you have to be willing to join my family because I’m not leaving.” Maggie
tells you that she chose her current job partly because the insurance company that Leonardo
worked for had offices in this town and he could transfer to the South and keep his job. Maggie
says, “During the past year, I’ve been going up there to see Leonardo at least once a month for
a week- end. I only had 2 days with him, and we spent all day Sunday at his mother and father’s
house. His mother treats him like a baby and does everything for him. I think she resents me for
taking away her little boy. She’s friendly enough, but there’s tension between us. Lately, his
parents have been talking a lot about us getting a house down the street from them. I just
couldn’t stand that!” Maggie states that she began feeling like an outsider and an intruder.
“Leonardo was unhappy unless I agreed to every- thing he wanted,” Maggie says glumly.
Maggie states that since the breakup she has had great difficulty sleeping. She often sleeps only
2 or 3 hours a night. She states that she has also lost her appetite and has dropped 15 pounds
in the past month. In a very shaky voice, she tells you, “I’ve been having so much trouble with
my job lately. I can’t focus on what I’m doing for more than 3 minutes before I’m off thinking
about Leonardo. It’s so hard it makes me want to cry.” She says she’s missed work completely
on four occasions during the last month when she just stayed in bed all day and watched soap
operas on TV. Since the breakup with Leonardo, she says she feels ugly, unlovable and hopeless
about ever getting married.
You decide to find out more about Maggie’s difficulties over the past month. You ask her if
there are any other ways in which the breakup with her boyfriend has affected her. She tells
you that she is normally a very avid reader of mystery books and lately hasn’t been able to get
past the first chapter. She also likes to go to community events on the weekends with friends,
but since she has lived in this town, she has been so consumed with her work and her
relationship with Leonardo that she hasn’t made any good friends. “Oh, you know, I’ve got- ten
acquainted with some people, but I don’t know them very well and it just seems so hard to pick
up the phone and call them. I doubt if they’d want to do anything with me anyway. I think I’m
just a loser all the way around.” You ask her if she really thinks it’s over with Leonardo. She
states that the last time he called, they just got into a shouting match. “By the end of the
conversation I decided I just had to end this relationship and get on with my life,” Maggie says
despondently. “I really believe that, too. I just don’t know where I’m going to find the energy to
do it. When I do sleep, I have nightmares about fights with Leonardo. It’s begun to take its toll
on me, I think.” You say, “Maggie, you’ve mentioned having problems sleeping, and I was
wondering whether you were having trouble going to sleep or problems waking up in the
middle of the night and not being able to get back to sleep.” Maggie states that her biggest
problem is her inability to sleep through the night. She says she wakes up around 2 a.m. and of-
ten cannot get back to sleep until it’s almost time to get up. “Then I feel groggy and unable to
function very well the rest of the day,” she hesitantly tells you in a quiet voice. You also ask her
if she’s had any suicidal thoughts or had any plans for hurting herself due to this upsetting
situation. Maggie responds that she has thought about just wanting to end all this pain,
especially at night when she is alone. You ask her if she has taken those thoughts any further
and considered how she might “end it all.” She tells you that she doesn’t think she could ever
actually hurt herself since it is against her religion and she believes it would be wrong to
commit suicide. You explain to Maggie that if she ever begins having thoughts of how she might
hurt herself that it would be important for her to talk with you about those thoughts and
feelings. Maggie agrees that she will discuss those issues with you should they arise. When you
ask Maggie about her family of origin, she states that she’s always gotten along well with
everyone in her family except her mother. She says that ever since she was little, her mother
has wanted her to always act like the oldest. “She always tells me that I have to be the
responsible one because I’m
the oldest, and I don’t think she really cares about whether I’m happy or not.” When Maggie
told her mother that the relationship with Leonardo had ended, her mother just told her to
grow up and get over it. Maggie says she’s never been able to go to her mother with a problem.
“I’m not sure my mother is a very happy person. She’s more concerned about what the
neighbors will think than whether or not we are content with our lives. Ever since I was little,
my mother would get in one of her moods and close herself in the bedroom and not come out
for days.” Maggie states that she has a much closer relationship with her father, who has called
several times to see if she’s okay. Before leaving your office, Maggie tells you she’s really glad
she came to talk today. She says, “It’s taken a big load off my shoulders.” Maggie states that
this is the first time in several weeks that she can remember not having a headache. She agrees
to come back and see you at the same time next
Source:
Pomeroy, E. (2014). Clinical Assessment Workbook: Balancing Strengths and Differential
Diagnosis. Pages 113-114. [VitalSource Bookshelf]. Retrieved
from https://bookshelf.vitalsource.com/#/books/9781305480926/
