Social History for an Imaginary Client

Identifying Information

Name: Walter Jones	Age: 56	Case #:
Date of birth: 10/2/1967	Male
Address: Downtown, NYC	Home Phone: N/A Cell Phone: N/A Email: [email protected]
Additional identifying information: The client is a cisgender Caucasian male. He lives with his wife in an apartment in Downtown New York.

Presenting Problem

The client was referred to the clinic for management of depression. He has been battling depression for the past seven years and is currently on fluoxetine. He has had two suicidal attempts in the past two months, prompting his referral to the clinic.

The client’s perception of the problem

The client recounts that he has been battling depression for a long time. His diagnosis, seven years ago, came after a failed suicidal attempt. He notes that his depressive symptoms began manifesting after the loss of his two kids in a fire incident in their Manhattan house. He understands the severity of his disease and is willing to participate in care interventions targeting to alleviate his suffering.

Client’s background/Family of origin

The client is a Caucasian male. He is the firstborn in a family of seven. His father and mother are still alive and live in New Jersey. All of his four siblings are also alive. He moved to New York for his college education and has since been living there. The client’s family is well-off. His father is a millionaire owning several properties in New Jersey. The client was born in a hospital in his hometown. At the time of his birth, his parents were experiencing a tumultuous moment in their marriage and were on the verge of a divorce. This prompted them to hand him over to foster care by his grandmother until the age of seven. His grandmother is a known alcoholic and smoker and lives in a violent neighborhood in a suburb of New York.

Education

The client is a college graduate. He graduated with a degree in electrical engineering from New York University. He has received an informal education in leadership from Brooklyn Learning Center. He attended the Far Hills Country Day School, NJ, for his high school studies.

Employment

The client owns a software firm in New York. Before venturing into entrepreneurship, he was employed in three different companies, with short stays in each. He noted that he was released from those companies due to underperformance. He attributes his failures to depression. He narrated that he used to have feelings of emptiness and worthlessness when working with the companies and resorted to drinking alcohol to “feel okay.” This affected his work.

Medical history

The client was hospitalized for an alcohol overdose when he was thirty. He has been involved in several minor accidents. Most of the accidents are attributable to alcohol use. He is up to date with his vaccinations.

Mental/Emotional health history

The client was diagnosed with depression seven years ago. He has since been receiving treatment. Three years ago, he was diagnosed with substance abuse disorder and depression comorbidity, which was managed effectively through counseling and pharmacotherapy.

Substance use history

The client has a positive history of alcohol and substance abuse. He has been taking alcohol since his college days but has since stopped. He is an occasional smoker and has a history of marijuana use.

Legal and criminal background

The client has been arrested and charged with drunk driving on at least three occasions. On one occasion, he was also charged with causing injuries to pedestrians through reckless driving. His driving license has since been revoked.

Social support system, including religious and spiritual beliefs

The client is Catholic. He notes that he connects with his spirituality whenever he is low and goes to church occasionally. He also has a supportive wife and is close to other members of his family. His wife and family are his source of social support.

Housing status

The client owns an apartment in downtown New York.

Economic status

The client owns a software firm. He is well off and can afford all his basic needs and luxuries. He also comes from a rich family.

Assessment and recommendations

Client’s Needs:

The patient is alert and oriented to space, time, and events. He is properly dressed for the occasion and demonstrates clarity in speech. He denies any hallucinations or delusional thinking. The subjective assessment of the client reveals a history of experiences and behaviors that may have predisposed him to depression. His childhood experiences, substance abuse behaviors, and depressive manifestations are all suggestive of major depressive disorder. The presence of suicidal ideation and tendencies are indicative of the severity of his disease.

Client’s Strengths:

The client acknowledges his suffering and is willing to take part in his treatment process.

Barriers to Treatment:

There are no identifiable barriers to managing the client as he is cooperative with care interventions.

Intervention/Treatment Plan

Treatment goal #1: To lower depressive symptoms and allow the client to get back to his normal life

This will be accomplished by 8/5/2023.

Step 1: Psychotherapy

The person responsible for taking action: Psychologist

Step 2: Pharmacotherapy

The person responsible for taking action: Psychiatrists, pharmacists, and psychiatric nurses

Treatment goal #2: To lower suicidal tendencies and thoughts

This will be accomplished by 8/5/2023.

Step 1: Electroconvulsive therapy

The person responsible for taking action: Psychiatrists and anesthesiologists

Step 2: Pharmacotherapy.

The person responsible for taking action: Psychiatrists, pharmacists, and psychiatric nurses

Signatures

Social Worker:

Supervisor:

Date:

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Question

Read the Social History Guidelines handout, and follow the instructions below to complete the assignment.
Write a social history for an imaginary client. Base your client on a favorite fictional character (e.g., Snow White, Scout, Lois Lane, etc.). Use your imagination to complete the social history in detail. If certain details are not available from the character’s story, you may use a creative license to complete the assignment. Don’t leave out important Social History details!

Social History for an Imaginary Client

Download the Social History Template and New Client Intake Form. Create a narrative social history using the information you “collected” from your client on the Social History Form and New Client Intake Form. Your narrative social history should use headings. Under each heading, write a brief narrative statement or paragraph regarding the client. Be sure to write in complete sentences, and use a new paragraph when changing topics or key points.

Social History for an Imaginary Client