I received documents from USC- Columbias counseling Center, and health records from his primary doctor. I had consent from the client as well as his counselor and his primary physician. The client followed counselors advice and made an appointment with me voluntarily. Description and development of presenting problem
Louis is currently in counseling where his counselor suggested he specifically seek stress and anxiety management. He is a full time student who is struggling to balance the demands of college and time management which has recently triggered a significant amount of stress and anxiety. My client sought my assistance after struggling to complete assignments on their due dates. Family History
Louis currently resides in Columbia but is originally from Greenville, South Carolina. In Columbia, he lives with two roommates. Their names are Brandon and Jeffery. They are both Jewish white male students in their twenties. Louis and his roommates take part in a Jewish fraternity. Louis is the second child to Jane and Rueben Sutter.
His parents are middle aged. He has an older sister named Jori who is twenty seven. Louis is very close to his mother, Jane. Louis is also close to his maternal grandfather. He does not interact that much with his paternal family. Client History
Louis was born on March 20, 1991. He graduated high school in 2009. He enrolled in college and plans to graduate May 2014. In 2007 he reports that he struggled with the academic demands of high school. In that same year, documents note that Louis was tested for learning disabilities and psychological disorders. His physician and psychiatrist suggested medication and therapy. See attached document for specific past medications.
After some trial and error, my client is currently taking Pristiq and Adavan. My client and medical records show that he takes 80mg Pristiq daily and 50mg Adavan when needed. My client says he is satisfied with his meds and the dosages. He also informed me that his mother and sister suffer from anxiety and depression. My client suggests a healthy intimate relationship because he has been dating the same girl for two years and is content. He has no criminal record or legal issues which were verified with a background check. He mentioned that he has never had an issue with drugs or alcohol. Current Situation
Despite the anxiety and stress, Louis appears to be a positive, healthy and happy person. He takes part in a Jewish college fraternity, has a good support system, takes part in some Jewish traditions as well as participates in activities related to his major. He seems enthusiastic about classes, just struggles to meet deadlines, procrastinates as well as feels nervous when doing assignments. He wants to complete assignments confidently but says he is always second guesses himself.
My client is a full time student who does not work during when classes are in session. He states that his parents financially support him as well as his saving from working in the summers. He says with his savings and parents help, he is able to pay for food, rent and bills. He has his own transportation and is able to get around town, to classes, internship and social events. He says he is more of a cultural Jew than a religious Jew.
Planning, Implementation, Evaluation, and Termination