Case History: I am Sam
1
Forman Christian College University
Course Code: Psyc 498
Course Title: Psychology Internship
Case History: 2/I am Sam
Personal information
Client’s Name: S. D.
Age: Around 40
Gender: Male
Religion: NA
Language: English
Marital Status: Married but wife left him
Education: NA
Occupation: Waiter at Starbucks
Referral Source: Judge
SES: Middle-Class
Presenting Problems
The client was referred by the Judge for the management of the following presenting complaints:
• I make sure everything is perfect at Starbucks; the salt and pepper, the sashays,
• I have to reach on time
• Over caring
, Case History: I am Sam
2
• I cannot read long words.
• Sometime I cannot control my emotions
• I don’t know when people are being indirect with me
• I cannot do math
• I cannot remember some things
History of Presenting Problem:
The client said that the presenting problems have been there ever since he were born. They
did not go into any details.
Personal History:
Information about the following could not be obtained:
Problems during birth
Prenatal problems
Unusual events such as head injuries or trauma
Developmental milestones
Personality as a kid
Medical History:
Client reported that he had been admitted to an institution before to look after him when his
mother fell sick and nobody was there to care for him.
Prior Mental Health Treatment:
The mother when she fell sick admitted him to an institution for his mental disability.
Psychiatric Medication:
He was currently on no Psychiatric medications. Information about past medications could
not be obtained.
1
Forman Christian College University
Course Code: Psyc 498
Course Title: Psychology Internship
Case History: 2/I am Sam
Personal information
Client’s Name: S. D.
Age: Around 40
Gender: Male
Religion: NA
Language: English
Marital Status: Married but wife left him
Education: NA
Occupation: Waiter at Starbucks
Referral Source: Judge
SES: Middle-Class
Presenting Problems
The client was referred by the Judge for the management of the following presenting complaints:
• I make sure everything is perfect at Starbucks; the salt and pepper, the sashays,
• I have to reach on time
• Over caring
, Case History: I am Sam
2
• I cannot read long words.
• Sometime I cannot control my emotions
• I don’t know when people are being indirect with me
• I cannot do math
• I cannot remember some things
History of Presenting Problem:
The client said that the presenting problems have been there ever since he were born. They
did not go into any details.
Personal History:
Information about the following could not be obtained:
Problems during birth
Prenatal problems
Unusual events such as head injuries or trauma
Developmental milestones
Personality as a kid
Medical History:
Client reported that he had been admitted to an institution before to look after him when his
mother fell sick and nobody was there to care for him.
Prior Mental Health Treatment:
The mother when she fell sick admitted him to an institution for his mental disability.
Psychiatric Medication:
He was currently on no Psychiatric medications. Information about past medications could
not be obtained.
