Reason for referral: The client reported he accidentally dropped his then 3-month-old daughter will he was sleeping. Deandre reported his daughter was laying on his chest. Denadre reported he believes when his daughter fell off him that her head hit a table.  The client denies that he abused his daughter however, in the referral it was stated that the client admitted to shaking his daughter.

PHYSICAL HEALTH ; client reported a history of having asthma that began when he was approximately 20 years old. The client reported he uses an inhaler as needed. Client reported he was stabbed once by his ex-girlfriend Desjanae Shields, brother, client reported his lung and heart was puncture and required emergency surgery client reported having ongoing problems with breathing since the incident. The incident occurred when the client was 22 years old.  Deandre’s daughter Saniyah Robinson was born at Memorial on February 15 2023 in South Bend Indiana.  To his knowledge, his daughter is up-to-date on her immunizations. He reported his daughter’s pediatrician practice is located at Beacon medical group in South Bend Indiana and her pediatrician’s name is Bailey Swan. Deandre reported he too sees the same doctor who prescribes his medication for his depression and anxiety.

Childhood trauma Client reported being spanked by his adoptive mother, however, he denies this to be trauma, client was abandoned at the age of 7 months, however, he describes this as not affecting him in any way during the interview, the client appeared to deflect and change the subject when this was brought up stating that he was okay, he reported at the age of 16 getting into contact with his bio mother and stating presently that he talks with her and that he has a “decent” relationship with her. Clint reported never knowing his father. He reported “not caring” that his father was not part of his life. Additionally, client never had a father figure in his life.

Deandre Robinson is a 24-year-old African American male born in Chicago Il and moved to South Bend Indiana at the age of 18. Deandre was born to Cherilyn Robinson. Deandre reported it was explained to him at 7 months old, his biological mother lost custody of him, and he never knew his biological father and he was adopted by Vanesa Wade. He reported Vanesa was a single parent. Deandre reported his birth mother had six children, he was the third born to his biological mother.  His bio siblings include Aetna Robinson (23), Kimberly Robinson (27), Miesha Robinson (28), Kiera Robertson (30), and Antoinette Robinson (21). Deandre reported that Vanesa also adopted two of his sisters, Kimberly and Miesha.The client has three adoptive siblings Marcus Wade, Bridgette Wade, and Kacey Wade. Ages unknown. The client reported that he had a good relationship with his adoptive siblings.

. Deandre described Vanesa as being a good mother to him and his sisters. He reported she was very loving and caring to him. However, he did describe her as being a strong disciplinarian. He described as a child he would get spanked often when he did things that did not align with the rules, such as getting into trouble in school Client reported his adoptive mother worked at Harvey Park district in Illinois, Deandre reported while his adoptive mother was working, he was watched over by his neighbors, and during summers he would attend the summer program where she worked.

He also normalized his spanking stating he understood why he got spanked. In addition to stating that was the way, things were back in the day. Deandre reported having a good relationship with his siblings he reported that he still talks to them presently. The client reported he did well in High school and had no problems making friends. But stated people are dumb, they talk to crazy to him which sets him off and people lie. He described his grades as A’S B’S and C’S.. He graduated from Thornwood  High School in Dolton Il in 2017. The client reported he attends Post University online. He reports his major is  sports management. Substance use as a coping mechanism Client reported he smokes marijuana and began at the age of 17 years old. Client reported he smokes two blunts a day he was not able to say how many grams.

At the age of 18 client reported he moved to south bend to pursue a romantic relationship with a  past girlfriend but it did not work out, some time later he started a new romantic relationship which resulted in the two breaking up due to what he first described as a domestic dispute. The client blamed his ex for the dispute and denied having any role in why they were arguing which resulted in him being stabbed by the girl’s brother.

The client reported he met his daughter’s mother approxateitmly one year ago and moved in with one another right away, he reported that she moved out of the apartment after the incident with their daughter noted above. He reported during their relationship the two did not get along with each other, and constant arguing. Deandre reported that he would never harm his daughter, he describes how much he loves and misses her. He reports it has been three months since he last seen his daughter.

Resources: client reports he applied for rental assistance and is awaiting a decision, the client receives Medicaid, and he works for Meijer 20 hours per week earning 15 per hour. The client reports his rent is 1050.00 per month. The client did report he is struggling with staying afloat since he and his girlfriend split. The apartment where he is staying is in his and his child’s mother’s name, they are both on the lease

Strengths: The client described his strengths as being neatly groomed, active and caring

Needs and motivation to change:Client report he understands that he has to get his anger under control and deal with his mood swings. Client reported he is willing to due what is necessary to improve these areas.

Support network: The client reported his support is his adoptive mother. Who provide love and guidance. She can be reached at the number on file

Mental health However, although the client reports his life was well, he reported a diagnosis of depression and anxiety,  he described having an IEP put in place when he was in the fourth grade, for his behaviors, the client reported he has a history of explosive anger, Client reported he was previously taking Prazosin 1mg, but now he is taking Venlafaxine 37.5 mg  2x per day Client reported he began counseling services one week ago, at Positive Change in South Bend.  Today, the client is moderately distracted and has thoughts that are slightly tangential. He is in a normal mood range. His attitude is self-centered. His  affect is labile. His memory is selected for recent and remote events. He is well-oriented to place, time and person.

CRIMINAL: The client denied any criminal history

Substance use Client reported he smokes marijuana and began at the age of 17 years old. Client reported he smokes two blunts a day he was not able to say how many grams.

1.PROVIDE A SUMMARY IN A DETAILED SUMMARY OF DEANDRE’S FAMILY HISTORY, INCLUDING SIBLING’S NAMES AND AGE, WHAT THEIR RELATIONSHIP IS LIKE HIS CHILD AND HOW HE DESCRIBES HIS RELATIONSHIP WITH HER, HIS PARENT AND WHAT THE RELATIONSHIP IS LIKE ROMANTIC RELATIONSHIPS,  IN SUMMARY INCLUDE WHAT HIS LIFE WAS LIKE GROWING UP, INCLUDE HIS DEMOGRAPHICS  INFORMATION FOR DEANDRE, INCLUDE HIS SUBSTANNCE USEAGE

2. summarize DEnadre physical health

3. Provide a thorough MSE based on the information

ANSWER

A Comprehensive Understanding of Deandre’s Background and Well-being

Family History and Relationships

Deandre Robinson’s family history is a complex blend of adoption, biological ties, and relationships. He was born to Cherilyn Robinson but was adopted by Vanesa Wade, who became his single adoptive mother. Deandre’s biological mother lost custody of him when he was just 7 months old. He has six biological siblings: Aetna, Kimberly, Miesha, Kiera, and Antoinette. Vanesa also adopted his sisters, Kimberly and Miesha. Despite the complexities, Deandre seems to have maintained a positive relationship with both his biological and adoptive siblings. He describes his adoptive siblings as being in good terms and still communicates with them.

Regarding his daughter, Saniyah Robinson, she was born at Memorial on February 15, 2023, in South Bend, Indiana. He believes she is up-to-date on immunizations and has a pediatrician at Beacon Medical Group named Bailey Swan. Deandre reports a strong bond with his daughter and expresses his love and longing for her, despite his tumultuous romantic relationships.

Physical Health

Deandre’s physical health is influenced by his history of asthma, which began around the age of 20. He uses an inhaler as needed to manage his asthma symptoms. Additionally, Deandre has experienced a traumatic incident where he was stabbed by his ex-girlfriend’s brother, resulting in punctured lung and heart, leading to ongoing breathing issues. This incident occurred when he was 22 years old.

Mental Health and MSE

Deandre’s mental health reveals a history of depression and anxiety. He reported a diagnosis and described being on medication. He has shown signs of explosive anger and has received an IEP (Individualized Education Program) for his behaviors when he was in the fourth grade. He recently began counseling services at Positive Change in South Bend.

Based on the available information, Deandre’s Mental State Examination (MSE) indicates a moderately distracted state with slightly tangential thoughts. His mood falls within a normal range, but his attitude appears self-centered, and his affect is labile. His memory is selected for recent and remote events. Deandre displays good orientation to place, time, and person.

Reflection

Deandre’s background highlights the complexity of family dynamics and relationships. It’s evident that his experiences, including adoption, abandonment, and reunification with his biological mother, have shaped his perspective. His struggles with mental health and substance use reflect the challenges he faces. This assignment has shown how critical it is to consider the holistic picture of an individual’s life, including their relationships, physical health, mental well-being, and personal history, when assessing their overall well-being.

Unresolved Question

Considering Deandre’s history of explosive anger and mental health challenges, I wonder about the effectiveness of his recent counseling services at Positive Change in South Bend. How will these services help him manage his emotions, and what strategies will be implemented to support his overall mental well-being?