Initial Interview (Mental Status Exam)

Lonna Shelton-Soward

Liberty University

Project 1: Initial Interview
Identifying Information
Sienna Jackson-Showers a 20 year old, single female Liberty University student lives resides at 3456 Crystal Ave., Park, MD 20947. Her number is 202-789-5678 or work 301-496-2345. She is a Lifeguard and Child Care Provider at the YMCA. For an emergency contact Ty Mason number 240-789-4857 address 856 Pen Circle, Fredrick, MD 209876.
Purpose of Counseling/Presenting Problem
Would this examinee make a good Resident Assistant (RA) at Liberty University?
Physical Appearance
Presenting Appearance
Ms. Sienna Jackson-Showers is a 20 years old, African American female. She is a brave and courageous
She appears to have strong judgment and insight. Sienna has above average intelligence and favorable abstract skills. She had no problem spellings and reciting the definition of common homophones.
Mood and Affect
Sienna interview suggest she is a cheerful, confident, optimistic individual with suitable affect. The strong rapport built at the beginning of the interview was apparent. She was relaxed and poised anxiety free. The conversation flowed easily. Sienna refutes any plan or intent of suicidal or homicidal ideation. She does not believe she is in danger. Sienna reports she is not impulsive nor affected by failed test items.
Medical History and Current Status
Sienna describes herself as a vibrant healthy young athlete with asthma. No hospitalized have occurred from health issue. Her past medical records do not imply anything different. Sienna last route physical was in June 2013. She has no current health issues requiring immediate attention. Her asthma is under control. Albuterol is used on an as needed basis rarely. Sienna described herself as a good sleeper getting between 8 to 9 hours nightly. She describes her appetite as healthy, with no recent changes in appetite or exercise pattern. Past Counseling Experiences or Psychiatric History
Sienna comes from a healthy functional family. She has not needed to address any serious family or personal issues. No counseling needed. Sienna turns to