Purpose:
To present a full intake with comprehensive treatment plan.
Instructions:
1. With your partner, combine parts 1, 2, & 3 into one document.
2. Together, use feedback from Parts 1, 2, and 3 to correct any mistakes and issues. A perfect score on parts 1-3 does not mean that you do not have mistakes to correct. There are times when I give you full credit but still have feedback for improvements. Please make sure that you have reviewed the feedback from parts 1-3 thoroughly and made any corrections as advised.
3. Individually (without your partner) write a 1-2 paragraph reflection at the end of the document that addresses the following:
Reaction (your reaction to the intake itself, the activity, how you felt that it went)
Source (the source of your reaction; did something in particular affect that reaction?)
Implications (what does this mean for you as a student in the future?)
Plan (how will you change because of the activity?)
Group Members: Cierra Coleman, Jenny Pierre, Rachael Ruetz
Reason for Visit
Source of Referral: PCP
Chief Complaint: “I’ve been feeling very anxious and having panic attacks a few times a week.’’
History of Present Illness:
Linda is a postmenopausal woman presenting for psychiatric evaluation due to ongoing anxiety, panic attacks, poor sleep, and chronic low mood. She reports experiencing daily generalized anxiety for several years, with panic attacks occurring 2–3 times weekly, described as sudden episodes of intense fear, heart racing, and shortness of breath. She endorses difficulty falling asleep and frequent nighttime awakenings, for which she takes lorazepam 0.5 mg, currently using it 1–2 times daily. She also occasionally uses over-the-counter melatonin without consistent benefit.
Linda describes persistent fatigue, hopelessness, and poor concentration over the past six months but denies current suicidal ideation, anhedonia, or feelings of worthlessness. She endorses feelings of loneliness and reports limited social support, noting distant relationships with her adult children and minimal interaction with others. Psychiatric history includes a previous trial of escitalopram five years ago, which she discontinued due to GI upset and emotional blunting. She briefly attended CBT six years ago for anxiety but discontinued after six sessions, stating it was not helpful at the time. She has no prior psychiatric hospitalizations or suicide attempts but admits to being dependent on lorazepam. She denies current alcohol or drug misuse but consumes 2–3 cups of coffee daily and drinks 1–2 glasses of wine weekly.
Linda expresses interest in treatment but appears ambivalent about restarting medications due to past side effects and a sense of discouragement. She is seeking help primarily to reduce her anxiety, improve her sleep, and regain a sense of emotional stability.
Review of Systems
Psychiatric and Medical Review of Systems:
· Mania: Denies periods of elevated mood, decreased need for sleep, increased goal-directed activity, or impulsivity.
· Depression: Endorses occasional feelings of hopelessness and fatigue but denies crying spells, suicidal or homicidal ideation, worthlessness, or anhedonia.
· Anxiety/Panic: Endorses daily generalized anxiety and panic attacks 2–3 times weekly.
· Obsessions/Compulsions: Denies intrusive thoughts or repetitive behaviors.
· Trauma: Endorses witnessing domestic violence in her childhood home. Denies sexual assault or military trauma.
· Psychosis: Denies hallucinations, delusions, or paranoia.
· Memory/Concentration: Reports poor concentration and forgetfulness over the past six months.
· Sleep: Reports difficulty falling asleep and waking multiple times nightly. Uses lorazepam nightly to initiate sleep.
· Appetite: Endorses normal appetite; denies weight change.
Medical Systems Review:
· Neurological: Denies seizures, headaches, or dizziness.
· Cardiovascular: Denies chest pain or palpitations outside of anxiety episodes.
· Respiratory: Denies shortness of breath or cough.
· Gastrointestinal (GI): Reports occasional constipation; denies abdominal pain, nausea, or vomiting.
· Genitourinary (GU): Denies urinary frequency, urgency, or incontinence.
· Pain: Reports occasional back pain due to a prior car accident but denies chronic pain requiring medication.
Current Medications
· Lorazepam 0.5 mg PO PRN (current use: 1-2 times daily)
· Multivitamin daily
· Over-the-counter melatonin 5 mg PRN for sleep
Psychiatric History
· Medications: Previously trialed escitalopram five years ago but discontinued due to reported GI upset and "feeling numb." No other antidepressants or mood stabilizers trialed.
· Hospitalizations: None.
· Counseling/Therapy: Attended cognitive behavioral therapy (CBT) briefly six years ago for approximately six sessions but discontinued due to "not feeling it helped."
· Suicide Attempts: Denies past suicide attempts.
· Substance Use: Denies history of recreational drug use. Occasional alcohol use (1–2 glasses of wine per week). Admits to dependency on prescribed lorazepam.
Medical History
· Illness/Injuries: Diagnosed with hypertension five years ago, managed with lifestyle modification. No history of diabetes or chronic illness.
· Surgeries: Appendectomy at age 23. C-section at age 30.
· Allergies: NKDA (No Known Drug Allergies).
· Pregnancy/Contraception: Two children (ages 23 and 19). Not currently sexually active. Post-menopausal.
Habits
· Alcohol: Occasional (1–2 drinks per week), denies binge drinking.
· Drugs: Denies illicit drug use.
· Caffeine: Consumes 2–3 cups of coffee daily.
· Tobacco: Former smoker, quit 10 years ago; smoked for 15 years.
· Supplements: Takes OTC melatonin and a multivitamin.
Family Psychiatric History
· Mother: Diagnosed with generalized anxiety disorder, treated with diazepam for several years.
· Father: History of alcohol abuse and domestic violence. Died of liver cirrhosis.
· Maternal grandmother: Died by suicide at age 67.
· Brother: Diagnosed with depression and has a history of cannabis use.
Psychosocial History
· Developmental and Educational History:
Linda was born full-term via normal vaginal delivery. No reported developmental delays. She reports being a quiet child who “worries a lot.” She completed high school and earned an associate degree in office administration. Reports no learning disabilities.
· Current Family:
Divorced, lives alone. Two adult children who live out of state. Limited contact with ex-husband. Describes relationships with children as “distant but civil.” States she feels “very alone” much of the time.
· Social Supports/Faith:
Minimal social support. Occasional phone calls with an old college friend. No current involvement in community groups or religious organizations. Raised Catholic but does not currently practice.
· Adverse Life Events:
Reports of an emotionally abusive marriage lasting 18 years. Divorced 8 years ago. Also reports a traumatic car accident 7 years ago, resulting in mild concussion and chronic back pain. Childhood marked by witnessing father’s alcohol abuse and parental conflict.
OBJECTIVE MENTAL STATUS EXAMINATION: Appearance: Appropriately dressed and groomed. Appears restless, fidgeting with nails while answering questions. Maintains good posture and appropriate eye contact. Orientation: Alert and oriented to person, place, time and situation. Concentration: Concentration slightly impaired due to patient having difficulty performing serial 7’s. Manner: Cooperative and engaged. Speech: Normal tone, rate and rhythm. Mood: Patient reports feeling anxious, hopeless and fatigued. Affect: The patient's affect is congruent to their reported mood. Thought Process: Thought process is goal directed and logical. Thought Content: The patient reports feeling anxious and unable to control her anxiety. She reports feeling episodes of intense fear, shortness of breath and tachycardia that impacts her daily life. The patient also states she struggles with difficulty falling asleep and waking up multiple times in the night. Perceptions: The patient denies hallucinations, delusions and illusions Memory and Cognition: Short and long-term memory intact. Immediate memory impaired, patient unable to recall 1 out of the 3 items during the three-item recall test. Judgment: Judgement is intact due to the patient seeking medical help for her conditions. Insight: The patient displayed insight regarding the nature of their condition.
Collateral Information: *** Suicide assessment and treatment planning will be completed in future assignments.
Comprehensive Suicide Evaluation
Is the validity of the information contained within this evaluation in question?
__x__ No
____ Yes, due to patient being under the influence
____ Yes, due to the patient's medical condition (i.e. dementia, etc.)
____ Yes, due to other ____________________
Suicidal Ideation
———————–
Suicidal ideation: Thoughts of engaging in suicide-related behavior. For example, intrusive thoughts of suicide without the wish to die would be classified as suicidal ideation, without intent.
How recently has the patient had thoughts of engaging in suicide-related behavior:
__x_ Never
___ Within the last 24 hours
___ Within the past 1 to 7 days
___ Within the past 8 to 30 days
___ Within the past 2 to 6 months
___ Within the past 7 to 12 months
___ More than a year ago
Suicide attempts
—————————
Has the patient every made a prior suicide attempt? No
Suicide attempt: A non-fatal self-inflicted potentially injurious behavior with any intent to die as a result of the behavior.
If yes, how many suicide attempts has the patient made? ____________________
When was the most recent attempt? _______________________
What was the method used for this recent event? (overdose, physical injury, firearm, vehicle, injury by other person, other) ____________________________
As a result of this recent attempt, was the patient taken to any of these places or did the patient seek help at any of these places? (Physician/nurse, crisis outreach center, police/welfare check, paramedics/ambulance, hospital/medical center, other) _____________________________
Was the recent suicide attempt interrupted? If so, by self or other? _____________________
Did the recent attempt result in injury? ____________________
Was this most recent attempt the most lethal attempt? ___________________________
Has the patient engaged in any preparatory behavior aside from behavior associated with any suicide attempts documented above? No
Preparatory behavior: Acts or preparation towards engaging in self-directed violence, but before potential for injury has begun.
Warning signs
————————
Warning signs: Individual factors which signal an acute increase in risk that the patient may engage in suicidal behavior in the immediate future. These can be assessed by asking the patient to describe thoughts, feelings, and behaviors experienced prior to the most recent exacerbation of suicidal ideation or behavior.
Select all warning signs from each category.
Direct:
___ Preparations for suicide
___ Seeking access or recent use of lethal means
___ Suicidal communication
___ Other
Indirect:
___ Anger
_x__ Anxiety
___ Feeling trapped
___ Guilt or shame
__x_ Hopelessness
_x__ Mood changes
___ Purposelessness
___ Recklessness
__x_ Sleep disturbances
_x__ Social withdrawal
___ Substance use
__x_ Other: Loneliness
The following warning signs are currently present: ____yes___________________________
Risk factors
—————–
Risk factors may increase the likelihood of engaging in suicidal self-directed violence. They may be modifiable or non-modifiable and both inform the formulation of risk for suicide. Modifiable risk factors may also be targets of intervention.
___ Access to lethal means (firearms, large quantities of medication)
___ Financial problems
___ History of mental health hospitalizations
___ History of non-suicidal self-directed violence (cutting, burning)
___ History of suicide attempts
___ Homelessness
___ Legal problems
__x_ Losses
_x__ Medical conditions and health-related problems
__x_ Preexisting risk factors (history of trauma, family history of suicide)
__x_ Psychological conditions
__x_ Social/systemic problems (poor interpersonal relationships, barriers to accessing care, etc)
___ Other
Protective factors and reasons for living
—————————————————————-
Protective factors are capabilities, qualities, environmental and personal resources that drive individual toward growth, stability, and health and may reduce the risk for suicide. Enhancing protective factors can be a target of intervention.
__x_ Access and engagement with healthcare (supportive providers, motivated for treatment)
___ Interpersonal relationships (child-related responsibilities, strong bond to family members)
_x__ Positive personal traits or beliefs (help-seeking, religious or cultural beliefs against suicide)
___ Social context support system (community support, family responsibilities)
___ Other
Clinical Impressions
—————————————
Clinical impression of acute risk:
___ High risk
_x__ Intermediate risk
___ Low risk
Clinical impression of chronic risk:
___ High risk
__x_ Intermediate risk
___ Low risk
Risk mitigation plan:
___ Involuntary hospitalization
___ Voluntary hospitalization
___ Initiate health and welfare check
___ Initiate a hospital transportation plan
__x_ Complete a safety plan with patient
___ Increase frequency of outpatient contacts
___ Lethal means safety counseling
__x_ Address barriers to treatment engagement
__x_ Address psychosocial needs
_x__ Address medical conditions
__x_ Educate on emergency services
__x_ Initiate evidence-based psychotherapy
___ Involve family/support system
__x_ Pharmacotherapy intervention to reduce suicide risk
__x_ Provide patient with phone number to crisis line
==============================================================
SAFETY PLAN
===============================================================
Please follow the steps described below on your Safety Plan.
If you are experiencing a medical or mental health emergency,please call 911, at any time.
If you are unable to reach your safety contacts or you are in crisis,please call the Veterans Crisis Line at 1-800-273-8255 (press 1).
————————————————————————
Step 1: Triggers, Risk Factors and Warning Signs
————————————————————————
How will you know when you are in crisis and that the Safety Plan
should be used? What are your personal red flags?
1. Intense feelings of anxiety with heart racing, shortness of breath, or panic.
2. Social withdrawal — ignoring phone calls and avoiding contact with others.
3. Feelings of hopelessness and loneliness, especially when thinking about her children being far away.
4. Trouble falling asleep and waking up multiple times during the night.
5. Increase in negative self-talk (“I’ll never feel better,” “I’m a burden”).
————————————————————————
Step 2: Internal Coping Strategies
————————————————————————
What can you do, on your own, to help you stay safe and not act on
your suicidal thoughts or urges in the future? What have you done
in the past to stay safe?
1. Practice deep breathing and grounding techniques (e.g., 5-4-3-2-1 method).
2. Listen to calming music or guided meditation recordings before bed.
3. Go for a short walk in the neighborhood or stretch indoors.
4. Write in her journal to release anxious or negative thoughts.
5. Drink herbal tea and take a warm shower to help manage nighttime restlessness.
————————————————————————
Step 3: Social Contacts Who May Distract from the Crisis
————————————————————————
Other than mental health providers and counselors, who can you contact
who helps take your mind off your problems or helps you feel better?
Name: Mary J. (old college friend)
Phone number: (555) 234-7789
Name: Susan L. (neighbor she occasionally chats with)
Phone number: (555) 987-4432
Name: Patricia R. (church acquaintance she reconnected with recently)
Phone number: (555) 112-3344
What public places, groups, or social events help you feel better?
Examples of social settings include community events, beaches, parks,
coffee shops, malls, churches, clubs, 12 step meetings, aftercare
groups, support groups, organizations, social
events.
1. Local coffee shop she enjoys visiting on Saturday mornings.
2. Public library, especially the reading lounge.
3. Community center offering yoga and relaxation classes.
4. City park with walking paths.
5. Online support group for women managing anxiety.
6. Weekend farmer’s market downtown.
————————————————————————
Step 4: Family Members or Friends Who May Offer Help
————————————————————————
Who are friends or family members who should be included in your plan?
Name: Kayla K. (Daughter)
Phone number: (451) 347-6777
Name: Eric M. (Son)
Phone number: (727) 347-4571
Name: Mary J (College friend)
Phone number: (555) 234-7789
————————————————————————
Step 5: Professionals and Agencies to Contact for Help
————————————————————————
Who are the mental health professionals or professional peer supports
who should be included in your plan?
Please list the numbers you would call in the order you would call them.
Name: Robert Anderson (Psychiatrist)
Phone number: 555-567-3331
Name: Elizabeth Henderson (PCP)
Phone number: (555) 234-7789
Veterans Crisis Line: 1 – 800 – 273 – TALK (8255), press 1
Veterans Crisis Line Text Messaging Service: 838255
Veterans Crisis Line: https://www.veteranscrisisline.net/chat
Call "911" in an emergency
If you need to go to an urgent care center or emergency room,
where will you go?
Facility name: Tampa General Hospital
Facility address: 1 Tampa General Cir, Tampa, FL 33606
Facility phone number: (814) 844-7000
Local site-specific emergency numbers: Crisis Center of Tampa Bay. Dial 211 to speak with someone from the crisis center.
————————————————————————
Step 6: Making the Environment Safe
————————————————————————
Ways to make my environment safer and barriers I will use to protect
myself from these potentially lethal means: The firearm in the house should be locked and stored unloaded. The bullets for the firearm should be in a different location and locked. Additionally, using a cable or trigger lock for the firearm.
Patient has access to firearms: Yes
Firearm safety discussed with patient: Yes
Patient has access to opioids: No
Opioid safety discussed with patient and overdose education
provided including the use of naloxone: N/A
Naloxone prescription offered to patient: N/A
These are the people who will help me protect myself from having
access to dangerous items:
Name: Patricia R. (church acquaintance she reconnected with recently)
Phone: (555) 112-3344
Patient's current, physical address: 4555 W Swann Ave Tampa FL, 33609
Other Resources:
– My3 smartphone application (copy of Safety Plan on smartphone)
– Virtual Hope Box smartphone application (create a hope box to
remember good things in one's life)
– Maketheconnection.net (source of Veteran-related resources and
information)
– VetsPrevail.org (online therapy and/or chat with trained peer
support; can access online or on smartphone)
Patient has been given a copy of this Safety Plan.
Caregiver has been given a copy of this Safety Plan.
Provider may contact the following person(s) to check on safety:
Name: Mary J (College friend)
Phone: (555) 234-7789
Release of Information on file: (yes/no)
DIAGNOSTIC IMPRESSION: (an overall clinical summary of your impressions)
DSM-V diagnosis:
PLAN
– Medication:
The first-line recommendation is to initiate sertraline, an SSRI, as it has strong evidence for the treatment of both GAD and panic disorder. It should be started at 25 mg a day for 3-7 days and increased to 50 mg a day, and then titrated again as tolerated. Patients should understand that it will take 2-4 weeks for its therapeutic effects to become evident, with maximum benefit at 8-12 weeks (Franzoi et al., 2021). Early side effects tend to include gastrointestinal upset, mild sleep disturbance, or sexual dysfunction, and these tend to remit spontaneously. Also, if you're not tolerant to one of these medications, you might consider an alternative like sertraline or buspirone. Buspirone is especially useful for GAD and lacks the potential for dependence, and is thus a valuable adjunct to benzodiazepine taper.
A current concern with lorazepam maintenance is dependence. Long-term benzodiazepine use is not recommended because of constipating side effects, cognitive dysfunction, and falls among older adults. Pharmacologic tapering of 5-10% of the daily total dosage every 1-2 weeks is recommended (notably, tapering should normally be more gradual at the low doses). Patient education should include advising them that tapering decreases the danger of withdrawal, rebound anxiety, and insomnia. Repeated follow-up and use of CBT during the taper improve success rates.
– Labs/testing/referrals:
Baseline labs should include thyroid function tests, complete blood count, basic metabolic panel, and liver function tests, given her fatigue, cognitive complaints, and medication considerations. Vitamin B12 is also tested to determine if a deficiency plays a role in problems with concentrating. She does have a history of hypertension for which she should have follow-up for blood pressure changes, if ever an SNRI is contemplated.
Referral for sleep medicine consultation should be made for sleep apnea symptoms of gasping or snoring, or for a sleep apnea that is observed, and polysomnography for the diagnosis of obstructive sleep apnea should be considered in particular if the symptoms are especially severe or premature. The nonpharmacologic treatment of insomnia, and specifically Cognitive Behavioral Therapy for Insomnia (CBT-I), is highly recommended (Park et al., 2024). Pharmacologic sleep aid may also be considered short-term with trazodone or mirtazapine at low doses, but should be used sparingly and only if the behavioral assistance is not effective.
– Therapy referral with 2 SMART Goals: Cognitive behavioral therapy (CBT) referral
2 SMART goals:
1. Beginning September 9th, I will take 30-minute walks to manage my anxiety and perform this
Monday/Wednesday/Friday to decrease my anxiety symptoms for 4 weeks.
2. Beginning September 9th, I will perform box breathing that I learned in todays appointment for 3
minutes on Tuesday/Thursday/Saturday for 4 weeks to help manage my anxiety symptoms.
– Prevention measures with 2 whole health strategies:
1. Yoga: Yoga is a very great nonpharmacological strategy to decrease anxiety. After 1 month of
performing yoga, patient’s anxiety levels decreased substantially (Varambally et al., 2013).
2. Mindfulness: Mindfulness-stress reduction interventions are phenomenal tools that patients can
incorporate in their daily life to decrease their anxiety symptoms. Mindfulness-based interventions
have been proven to decrease anxiety symptoms in participants that utilized this technique (Hofmann &
Gómez, 2017).
– Education:
– Homework:
– Recommended follow-up for medications in _____ weeks or sooner if needed.
– Return to the clinic if condition worsens or new symptoms arise, medication side effects or
safety (SI/HI) concerns. If after duty hours go to the Emergency Department. For Emergency, call
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