Intake Summary and Treatment Plan for a Fictitious Client
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, 2
Intake Summary and Treatment Plan for a Fictitious Client
Bipolar and Related Disorders or the Depressive Disorder
Client Name: Karl Hudson
Client/Case Number: 00015
Date of Intake: 11/22/2023
Counselor/Therapist: Cathy Green
Identifying Information
Karl is a 19-year-old African American from Brooklyn. He recently dropped out of
college a few semesters to complete his engineering course, citing issues of low energy to
study. His mother brought him to therapy, citing increased levels of irritability, insomnia, and
trouble concentrating.
Presenting Problem
Karl explains that he wants to change his major to philosophy and is increasingly seen
engaging in debates about the nature of reality. He explains that he is just on the verge of
revolutionizing the world. When angry, he is sometimes withdrawn and spends most of his
time alone or sleeping. On several occasions, he has been reported engaging in high-risk
behaviors in cold water, drinking, and hitting on older women. He sometimes fails to go
home, avoiding arguments with his parents. He sometimes feels depressed, worthless, and
guilty about having lost his father's money going to college. However, he explains that he
cannot continue school, feeling weak enough to complete his studies.
In addition, the client sometimes feels worthless as he remembers past mistakes. He
keeps fixating on past failures and constantly blames himself for such downfall. Making
decisions and remembering things is another major problem he experiences. In the past few
months, he is reported to have attempted to commit suicide twice. He also expresses suicidal
thoughts when he suffers any setbacks. In the last two months, the client has been
experiencing excessive headaches combined with unexplained back pain. Currently, he does
not have hobbies and is no longer interested in the activities that brought him joy in the past.
Psychosocial Problem
Hudson is the only male child in a family with two sisters. He lives with his mother in
Brooklyn, where he was born. As the last-born child, he had the privilege of receiving care
from his older siblings. Five years ago, his parents divorced, which affected his mental state.
He was fond of his father, and the divorce made it impossible for him and the father to spend
time together. One year after the divorce, the mother could not afford to pay for their