COUC 521 Week 2 Project 1: Initial Interview Example

Project 1 Initial Interview: Intake Report for a Fictional Teacher Referred for Fatigue, Poor Concentration and Sleep Problems

Identifying Information

Megan Ross is a 29-year-old White woman who teaches second grade at a public elementary school in a small Ohio town. She is single, lives alone in a rented duplex and attends a Methodist church. She was interviewed for about 75 minutes in an outpatient counseling office. She arrived on time, completed intake forms without difficulty and consented to the interview and to communication with her referring physician.

Reason for Referral

Ms. Ross's primary care physician sent her for evaluation after four months of fatigue, poor concentration and early waking. Her physician's note reported normal results for thyroid function, a complete blood count and vitamin D, and asked: "Are her symptoms consistent with depression, or is something else going on, and what would help her function at work?" Ms. Ross said she agreed to come because "I'm running on empty and I don't know why."

Current Situation and Functioning

Ms. Ross reported falling asleep at about 10 p.m. but waking well before dawn, usually around 4 a.m., on most nights and being unable to return to sleep. She estimated sleeping five hours a night. She described tiredness that coffee does not relieve, difficulty concentrating while grading and planning, and forgetting tasks she once managed easily. She has lost interest in running, which she used to do three times a week, and reported that food "doesn't taste like anything," with a weight loss of about eight pounds since August. She denied thoughts of suicide or self-harm, now or in the past.

At work, she has taken four sick days this semester, which she said is more than she took in her previous two years together, and her principal has asked whether she is "okay." She continues to teach and said she still enjoys the children "when I'm with them, but I dread getting there." She has stopped attending a Thursday dinner with friends and now spends most weekends at home, watching television or sleeping in the afternoon. She described her mood as "flat, like someone turned the color down," and said it is worst on Sunday evenings before the school week. She reported crying alone two or three times a week, usually without a clear trigger, and feeling guilty that she is "letting the kids down." She denied panic attacks but described a steady sense of worry about falling behind.

Medical History

Ms. Ross reported no chronic medical conditions, surgeries or hospitalizations. She takes an oral contraceptive and no other medications. She reported two to three cups of coffee a day and light weekend drinking, usually wine with dinner, and denied tobacco or drug use. Her physician's laboratory results were normal, as noted above.

Psychiatric Treatment History

She has no prior psychiatric diagnoses or hospitalizations. During college, after her parents' divorce, she saw a campus counselor for six sessions and described it as "helpful, mostly to have someone to talk to." She has never taken psychiatric medication.

Family History

Ms. Ross is the older of two daughters. Her parents divorced when she was 20; her father lives nearby and her mother moved to Arizona. She described her mother as "anxious, always worried" and said her maternal grandmother "had nerves" and was hospitalized once for what the family called a breakdown. Her younger sister is in graduate school and they speak weekly. No family history of substance use disorders or suicide was reported.

Social and Developmental History

She was born and raised on a family farm in western Ohio and reported meeting developmental milestones on time. She described a happy childhood with heavy responsibilities as the oldest child. She has a small, close group of friends from college and church, has not dated in two years and described herself as "the one people come to, not the one who asks." Her closest friend moved to Indianapolis in June, which she mentioned twice during the interview, and she has not found anyone to fill that role. She volunteers in her church's children's ministry once a month and has continued doing so, although she said it now feels "like one more thing."

Educational and Occupational History

Ms. Ross earned a bachelor's degree in elementary education from a state university with honors and has taught for seven years, the last three at her current school. She was named her building's teacher of the year two years ago. This year she was assigned a larger class with several students who need significant behavioral support, and she said she has "never felt this far behind." She typically works until 6 p.m. and grades at home most evenings. She has not requested help from her principal or the school's behavior specialist, explaining that "everyone is stretched thin."

Cultural Influences

The ADDRESSING framework (Hays, 2016) asks clinicians to weigh age and generational influences, developmental and acquired disabilities, religion and spirituality, ethnic and racial identity, social class, sexual orientation, indigenous heritage, nationality and gender; several of these seem relevant. Her faith is important to her, and she wondered aloud whether her low mood meant she was "not trusting God enough." Her rural, farming background valued self-reliance, and she described asking for help as "something I'm not good at." Gender expectations around caregiving may also contribute to the pattern of giving support but not seeking it. Her church community is a potential source of support, and her religious concerns should be explored respectfully rather than set aside, since they may shape how she understands both the problem and the help she is willing to accept.

Summary and Next Steps

The intake suggests a pattern of low mood, early waking, loss of interest and appetite, and poor concentration emerging during a period of increased work demands, in a client with a family history of anxiety and possible depression. These findings are consistent with the physician's question about depression, but an intake alone cannot answer it. Drummond et al. (2016) emphasize gathering information from multiple methods before drawing conclusions, so the next steps are a full mental status examination, standardized measures of depression and anxiety and a personality inventory, with results compared against the diagnostic criteria (American Psychiatric Association, 2022). Ms. Ross agreed to return for further assessment and gave permission for results to be shared with her physician, who may also want to review her contraceptive and caffeine use as possible contributors.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Drummond, R. J., Sheperis, C. J., & Jones, K. D. (2016). Assessment procedures for counselors and helping professionals (8th ed.). Pearson.

Hays, P. A. (2016). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (3rd ed.). American Psychological Association.