Significant Medical and Counseling History.
Jane has been healthy most of her life, but now that she is getting older, she has noticed some changes in her health. Her physician has diagnosed her with fibromyalgia, high blood pressure and depression. She admitted that she should take medication for all of her issues in order to stay healthy, but the medication prescribed is very expensive and the health insurance she has only pays for a small portion, so due to her not having any income, she is not able to afford her medication at this time and does without.
Substance Use and Abuse.
She does not smoke, use any drugs, nor does she drink alcohol of any kind. She does believe she was physically and mentally by her parents throughout her childhood, due to her very harsh upbringing ways. Jane has not seen a therapist due to this abuse, but instead has dealt with the inner pain on her own. .
Educational and Vocational History.
As stated above, Jane married at the age of 19, she attended and graduated with honors from little creek high school and did not attend college. She never obtained a job after high school, but instead married one year after graduating, then soon started a family. While her children were in school, she volunteered in the food kitchens throughout their community, as well as volunteering for many school activities when needed.
Mental Status.
Jane Smith came to the counseling center at the appropriate time she was scheduled for. She was well dressed and very pleasant to the administrative office personnel when asked to fill out her paperwork before seeing the counselor. Upon assessing her actions on her first visit, she was very quiet and appeared nervous by shifted from side to side in her chair and looking down at the floor when speaking. After a brief conversation and discussing issues she has endured throughout her life, she admitted that she has been severely depressed since the passing of her husband and has not been able to bounce back as she had hoped.