Healthcare and Nursing Social Work Counselor Writeup
Role-play # ___: Topic of the Role-play
Counselor’s Name: ________________
Client’s Name: Lena Lana
Written By: ____________________
Summary Intake: Lena
General Background Information:
Lena is a 37-year-old women who is married with no kids. She is however, caring for her sister’s son and his name is John. After her sister was killed in a terrible accident 6 months ago, Lena was granted custody of her son who is 14 years of age and in the 9th grade. John was diagnosed with Schizophrenia and has been on medication for a year. This little boy has never met his father, nor has the father sought him out. Apparently John also hates visiting a psychiatrist and can at times be violent. This causes Lena to worry immensely. According to John’s family history, his father’s sister had schizophrenia and his mom was a drinker.
Lena has a full time job which keeps her quite busy, but she pushes for time and always makes sure she is around for when John may need her. She says she is depressed with the loss of her beloved sister and also because of dealing with her nephew’s difficult illness. Lena said that she thinks that without her sister in her life she is “all alone” and that the sadness she feels will never subside. Lena has come into counselling citing her depression and her nephew’s illness. Her goals are to seek medical management for her depression and therapy. She is seeking the help to see what she needs to work on to be able to cope with these feelings. An issue she brought up that she wants to work on is having more patience with her nephew, especially during his episodes which she does not even fully understand. She wants to receive more therapy without skipping any sessions like she has done in the past. She would also like that her husband help her out more with her nephew. She says that she understands that John is not his “biological son”, but that she would love her husband to show more support with the boy. Her goal for John is for him to take his medication more consistently and to attend therapy.
Lena and her family attend church at First Choice Deliverance every Sunday and she believes very strongly in her religion. She believes that it is prayer that will guide her through her depression. Lena says that her strength comes from the support of her family. She has no unusual medication that she is taking. Although, recently Lena has started to have drink twice a week to help ease her problems. Lena reports to have no allergies.
Presenting Problems:
PP1 Depression over sister’s death: Lena reported that was in a depressed mood due to her sister’s passing.
PP2 Anxiety and worry about nephew’s illness: Lena is overwhelmed by John’s illness and is worried about him.
PP3 Lena does not attend her therapy sessions: Lena has reported skipping a few sessions before.
PP4 Nephew does not take medications consistently: Lena is having a …
