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Comprehensive Client Assessment: Hernandez Family

Demographic information

• The Hernandez Family consists of two married parents, Juan and Maria Hernandez. Juan is 15 and Maria is 12 years old.
• This family is Hispanic and lives in the suburbs.
• Both parents have jobs, Mrs. Hernandez being a school teacher and Mr. Hernandez an employee in the construction industry.

Presenting the Problem

• Maria Hernandez, a daughter of the Hernandez family, has shown signs of anxiety and depression, which include withdrawal from her family and friends, as well as difficulty sleeping.

A History of Present or Past Illness

• Maria is suffering from depression and anxiety symptoms for more than three months.
• Her symptoms haven’t improved despite her receiving counseling from the school.
• Maria’s grades are dropping recently, despite her history of academic excellence.

Past Psychiatric Experience:

Medical History

• Maria is a healthy woman with no medical history.

History of Substance Use:

The Development of the World:

• Maria is developing at a normal pace, and has no major delays.

Families with a history of psychiatric illness:

Psychosocial History:

• Hernandez Family reports that the relationship between them has been straining recently because Mr. Hernandez works long hours, and Mrs. Hernandez feels overwhelmed by work and taking care of her children.
• Maria feels that her parents don’t support her and she is overwhelmed by schoolwork.

History of Abuse or Trauma

Examining Systems

• Maria experiences difficulty in sleeping, low appetite and sadness.

Physical Assessment

Test for Mental State:

• Maria is sad, and appears to be shedding tears. Her expression seems flat. She feels hopeless and overwhelmed.
• She does not have any hallucinations, delusions, or confusion about time, place, or person.
• She is displaying normal levels of attention and focus.

Differential Diagnosis

• According to the reported symptoms, it is possible to make a diagnosis of Major Depressive Syndrome.

The Case Formulation is:

• Maria’s symptoms of depression and anxiety may be related to feelings of pressure from school and a lack of support from her parents. Her family’s strained relationship may also be contributing to her symptoms.

Treatment Plan

• Maria’s treatment will consist of family therapy, which will address the communication and support in her family as well as individual therapy that addresses depression and anxiety.
• The management of medication will be discussed if necessary.
• Referral for a psychiatric evaluation will be made for a more thorough assessment of Maria’s symptoms and to determine the best course of treatment.