Summary: Clinical Impressions Including Mental Status Assessment

K is a 53 years-old Caucasian female. She identifies as heterosexual. K divorced after being married for 26 years and has two adult children. K indicates that her religious preference is Protestant Christian and was baptized recently. K’s pastor is present in her life and is an important part of her support system but K. mentions in group that she struggles with her belief. K believes that there is a higher Power. K has a GED; she did not graduate from High School. K studied online billing and coding and graduated in 2009. K worked in insurance and medical billing, she started when she at 18. During her last relapse, K left her last position where she worked for a couple of years. During those two years K was sober.
Clinical Impressions Including Mental Status Assessment

The client appears older than her stated age. During our first session, the client’s mood was guarded, angry and dysphoric, and her affect was congruent with her mood. K mentioned right away that she did not want to talk and that she did not see how this would help her. The client’s tone and body language reflected her mood. Her volume and rate of speech were normal. K appeared tense. Physically, the client was sitting straight in her chair with crossed arms and legs. The client was able to have eye contact except when she was on the verge of crying. K speech and thought process were coherent and logical. The client seemed to be of average intelligence, based on the content of her speech and her education. K was alert and oriented x 4. There was no evidence of perceptual