nu 674 unit 5 comprehensive assessment

 Comprehensive Assessment of Adolescent
Informed consent given to (mother) patient about psychiatric interview process and
psychiatric/psychotherapy treatment. Verbal and written consent obtained. Patient has the
ability/ capacity to respond and appears to understand the risk, benefits and (Will review
additional consent during treatment plan discussion)
Identifying data
Name: Jack Doe
Age: 16 years
Sex: male
Race: Black or African American
Occupation: student
Referral: Jane Doe (mother)
Informants: Jack Doe (patient), Jane Doe (patient’s mother) and Doe Jack (patient’s
father). The assessment was also based on reports from teachers at the patient’s school.
History: mother denies any significant medical history
Chief Compliant
“I often feel so unfocused but energized at the same time.”
History of Presenting Illness
16 y/o male that reports his teachers are complaining he is unfocused and disruptive in
class and that he lacks motivation. As per mother she is unsure where this behavior has
come from the last year, Jack grades continue to slip. “He prefers to be the class clown.”
As per mother has no significant past medical or psychiatric history. Patient lives at home