Assessment and Diagnosis Identifying Information

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Student Name
Author Note
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Case Presentation Template
Part 1 – Assessment and Diagnosis Identifying Information
Identifying Data
Date of Initial Assessment: 01/01/23
PSEUDO Name: Malvin R. Hawkins
Age: 41 years
Gender: Female
Sexual Orientation: Lesbian
Race/Ethnicity: Hispanic
Marital Status: Married
Employment Status: Employed and schooling
Reason for Referral/Presenting Problem
Malvin R. Hawkins reported for the therapy since she was experiencing symptoms of distress related to her childhood trauma, difficulties in managing her anxiety and triggering instances in her work. She reported that she had recurrent memories from her childhood that she did not want. Moreover, Malvin expressed having challenges avoiding distressing nightmares and thoughts, excessive worry, restlessness, detachment feelings, and fatigue. Also, she said she experienced relationship challenges with her spouse and communication distress with her mother.
Source of Information: This assessment's information was acquired from the therapy sessions of Malvin R Hawkins.
Background, Family Information, and Relevant History
The client is a 41-year-old Hispanic woman who is a lesbian and was raised in New Jersey (NJ), and lives in California. As per her report, she has four siblings. Malvin was raised in a Christian family but reported that she did not affiliate with her family's faith. She expressed challenging transitions during her schooling years and her difficult home life. Moreover, Malvin noted that she was taken from her home at the early age of 16 due to domestic abuse and, at 17, was emancipated. She is a high school graduate who attends school while maintaining her employment.
Problem and Counseling History
Malvin expressed problematic experiences of continuous, unpleasant memories from her past. She also spoke of challenges in avoiding distressing nightmares and thoughts, excessive worries, restlessness, detachment feelings, and fatigue. From her report, Malvin had problems in the couple in her relationship and communication distress with her biological mother. However, she noted that she lacked a counseling history as she had not attended counseling sessions.
Diagnostic Impression
Principal diagnosis: F43.10 Post-Traumatic Stress Disorder (PTSD).
Diagnosis 2 or z-code: F41.1 Generalized Anxiety Disorder.
Diagnosis 3 or z-code: Z62.820 Parent-Child Relational Problem.
Differential Diagnosis: Major Distress Disorder.
Discussion of Diagnostic Impression
Malvin's diagnosis revealed that she had Post-Traumatic Stress Disorder as her principal diagnosis. The diagnosis used her symptoms of recurrent memories that she considered unwanted, distressing nightmares, thoughts, and challenges of evading negative thoughts. Moreover, the diagnosis finds support from her domestic abuse and childhood trauma experiences. Furthermore, the diagnosis showed she had Generalized Anxiety Disorder considering her symptoms of sleeping challenges, excessive worries, restlessness, and fatigue. Also, Malvin was diagnosed with Parent-...