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Case File
Client Name: Christina Smith
Demographic Information
Legal Name: Christina Smith
Date of Birth: February 10, 1989
Address: 1520 Attokad Dr 83, S Sioux City, NE 68776
Gender Identity: Female
Sexual Orientation Choose not to disclose
Race Santa Rosa
Ethnicity South American
Languages English (primary)
Marital Status Legally Separated
Employment Unemployed
Religious Affiliation Christian (non-Catholic, non-specific)
HIPAA Signed HIPAA NPP on file
PCP Release Patient consented to release information
Smoking Status Former smoker
Diagnosis
Client lost her parents when she was younger. Due to losing her parents she was depressed and
she was admitted to a foster care where she was sexually assaulted by one of the workers.
, 2
When she left the foster care, she met a man and they started dating which later it became
abusive. Do that matter she started drinking insignificant amount of alcohol.
Major Depressive Disorder, Single episode, Moderate
Alcohol Use Disorder, Severe
Presenting problem
Christina is presented with depression and alcohol use disorder
Treatment goal
The goal for Christina’s treatment is to stop using alcohol and stay sober, alleviate depression,
and receive support to attend appointments.
Apply for scholarships to attend college.
So, to AA meetings
Stay healthy and clean
Objective
Christina feels depressed and uses alcohol. She experienced trauma, including parental loss,
sexual assault, and an abusive relationship.
Therapist suggested coping skills, and Christina requested a case manager to assist with
appointments, job seeking, and obtaining her license.
Treatment Strategy / Intervention
Case File
Client Name: Christina Smith
Demographic Information
Legal Name: Christina Smith
Date of Birth: February 10, 1989
Address: 1520 Attokad Dr 83, S Sioux City, NE 68776
Gender Identity: Female
Sexual Orientation Choose not to disclose
Race Santa Rosa
Ethnicity South American
Languages English (primary)
Marital Status Legally Separated
Employment Unemployed
Religious Affiliation Christian (non-Catholic, non-specific)
HIPAA Signed HIPAA NPP on file
PCP Release Patient consented to release information
Smoking Status Former smoker
Diagnosis
Client lost her parents when she was younger. Due to losing her parents she was depressed and
she was admitted to a foster care where she was sexually assaulted by one of the workers.
, 2
When she left the foster care, she met a man and they started dating which later it became
abusive. Do that matter she started drinking insignificant amount of alcohol.
Major Depressive Disorder, Single episode, Moderate
Alcohol Use Disorder, Severe
Presenting problem
Christina is presented with depression and alcohol use disorder
Treatment goal
The goal for Christina’s treatment is to stop using alcohol and stay sober, alleviate depression,
and receive support to attend appointments.
Apply for scholarships to attend college.
So, to AA meetings
Stay healthy and clean
Objective
Christina feels depressed and uses alcohol. She experienced trauma, including parental loss,
sexual assault, and an abusive relationship.
Therapist suggested coping skills, and Christina requested a case manager to assist with
appointments, job seeking, and obtaining her license.
Treatment Strategy / Intervention
