BIOPSYCHOSOCIAL ASSESSMENT IDENTIFYING INFORMATION (Age/Gender/Race): Nygo Hgo is a twenty-four year old Burmese female. PAYOR: Medicate insurance company will be paying for her services. Since she is considered economically poor, she has benefits through medicate. PRESENT PSYCHIATRIC ILLNESS/SYMPTOMS (Including current and past psychosocial stressors. Present psychiatric illness included depression and anxiety. Current and past psycho social stressor are the lack of respect from her community, moving to the United States, drug abuse and lack of funds which lead her to a down spiral. BASIC NEEDS & CONCERNS (Include transportation & housing concerns): Basic needs that Nygo needs are reliable transportation, better housing, English classes, counseling …show more content…
• Screen for and detect COD: June 21 2015 • Determine severity of mental and substance use disorders: June 21 2015 • Determine appropriate care setting (e.g., inpatient, outpatient, day-treatment): June 21 2015 • Determine diagnosis: June 27 2015 • Determine disability and functional impairment: June 27 2015 • Identify strengths and supports: June 27 2015 • Identify cultural and linguistic needs and supports: June 27 2015 • Identify additional problem areas to address (e.g., physical health, housing, vocational, educational, social, spiritual, cognitive, etc.): June 27 2015 • Determine readiness for change: June 27 2015 • Plan Treatment: June 27 2015 The twelve-step process was completed of a period of seven days June 21 to June 27 History of Withdrawal Symptoms: None Reported X AM alcohol/drug use Agitation Shakes Hallucinations High Blood Pressure X Suicidality Vomiting Violence Seizures Excessive Sweating Nausea X Anxiety Insomnia DT’s X Depression Other: ___________________________ History of Intoxification: X None Reported Blackouts Bumps/ Bruises Chest or Heart Pain Distended Abdomen Hallucinations High Blood Pressure Liver