Service Needs Assessment and Clinical Diagnosis
Client Name: John Doe Jr. Insurance #: 12345678910
DOB: 2/12/2001 Date of Assessment: 1/25/2016
Referring Agency: Norfolk Probation and Parole
Referring Worker: Ms. Johnson
Staff Evaluator:
Licensed Clinician:
Date of Clinical Diagnosis:
Identifying Information:
John Doe Jr. is an 15-year-old Biracial male who lives at 5115 Hampton Blvd, Norfolk, VA
23529. John resides with his mother, Jane Doe, age 42, his brother, Justin Doe, age 16, and his
sister Sally Doe, age 13. John has a small scar under his left eye.
Reason for Referral:
Ms. Johnson, Assistant Principal at S.W. High School, referred John to this agency due to
aggressive outbursts toward peers when angered, difficulty controlling his anger in an
appropriate way resulting in extended periods of time to “cool down” and non-completion of
assignments, provoking younger peers toward aggressive actions, frequent non-compliance with
rules and expectations in the school setting, and displays of disrespect and defiance toward
authority figures.
Presenting Issues:
During assessment, Mrs. Jane Doe, who is reported to be John’s biological mother attended
assessment. Both she and John identified his continued inability to sustain normal interpersonal
relationships as well as continued conflict with peers and family on a daily basis in all settings.
In the home setting, Ms. Doe reported John being constantly involved in altercations with his
siblings on a daily basis in the home setting. At the time of intake, Ms. Doe described these
altercations as screaming and yelling and John often encouraging his sisters to inflict serious
bodily harm to themselves (i.e. why don’t you just go kill yourself) and having a history of
resorting to inflicting bodily harm by punching his sibling when enraged. Per Ms. Doe, John
displays this behavior on a daily basis over 5 times per day, which causes a constant disruption to
the family unit. In addition, John has extreme difficulty managing feelings and emotions as well
as responding appropriately to challenging situations often erupting into angry outbursts, and
displaying severe mood swings (i.e. blaming others, yelling, stomping, and screaming) on a daily
basis. When asked how these mood swings are triggered, Ms. Doe explained that he “explodes”
when authority figures ask him to take responsibility for his behavior, or receives a negative
outcome while interacting with others such as losing at a video game. In the home setting, Ms.
Doe reported John’s emotional deficits as “sucking his teeth, stomping up the steps, talking back,
huffing and puffing and yelling out.” In the home setting Ms. Doe reported John’s emotional
deficits occurring on a daily basis and increasing in severity beginning in September of 2009
although she could not identify a significant cause for his change in behavior. During the intake
process, John displayed a severe change in mood and affect when discussing his relationship
with his biological father, John Doe who recently remarried in the beginning of 2010. When
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processing his relationships with others, John verbalized ongoing feelings of rejection and
abandonment from his father as a result of his father’s blatant display of favoritism toward
John’s sisters (i.e. buying his sisters clothing and taking them on outings and excluding John)
that contribute to his overall display of aggression and sibling rivalry toward his siblings. At the
time of intake, John reported harboring feelings of abandonment and resentment toward his
father as a result of his lack of communication and meaningful paternal contact, which
exacerbates his aggressive behaviors toward his siblings.
In addition to displaying severe emotional deficits as well as being involved in constant conflict
in the home setting, Ms. Doe described John as severely distractible and having significant
difficulty with completing assignments and tasks on a daily basis. Ms. Doe indicated that John is
severely distractible in the home environment, as evident by his needing directives to be clarified
or repeated on average of 3-4 times before he will comply or become disoriented by complex
commands, for example if John was asked to “put his clothes away and brush his teeth”, he puts
his clothes away but does not complete the task of brushing his teeth. Furthermore, John’s
distractibility presents a challenge when asked to complete his homework. Ms. Doe reported that
she must stand over John to redirect him during the entire time he works on his schoolwork
because he is highly distracted. She explained that she must redirect his inattentiveness “about
every five minutes” due to his high distractibility during his daily homework time.
John’s problematic behaviors often manifest in the community setting as a result of John’s
continued inability to sustain positive peer relationships as well as manage feelings and emotions
effectively. In the community setting, John has been involved in physical altercations with peers
as a result of his inability to manage anger or respond to challenging situations effectively. In the
community setting, John reported that the most violent thing he ever did was get into a fight with
his friend in the front yard of his house punching him numerous times inflicting bodily injury
(i.e. drawing blood) after being triggered by his brother in the home setting. In regards to this
incident, John explained that he was not upset with his friend but rather his brother; however, he
took out his anger on his friend when his friend asked him what was wrong. In all settings, Ms.
Doe reported that John often erupts into unmanageable and aggressive behaviors that often result
in confrontations and conflict as a result of John’s possession of a negative body image. Ms. Doe
indicated that John hates to be criticized and is particularly sensitive to being called “fat” which
is a major trigger for his reactive aggressive behaviors. At present, John currently resides in a
high crime area of Norfolk, known for drug trafficking and high risk gang activity. John’s
involvement in conflict in the community setting place him at continued risk of personal danger
due to three weeks prior to intake, a shooting of a local teen occurred in client’s neighborhood 3-
4 blocks from client’s home.
Current Living Situation, Family History and Relationships:
John resides with his mother, Jane Doe, his brother, Justin Doe, his sister, Sally Doe. Ms. Doe
reported that John’s father lives on the same street as John, two houses away. She reported that
John visits his father on a daily basis. John expressed a tumultuous relationship with his father.
He explained that his father is “the kind of person who will tell you what he really thinks”. John
said that his father does not hold back criticism but John knows his father still loves him.
However, John said that sometimes he does not “feel” as though his father loves him.
Throughout the assessment process, Ms. Doe expressed being the primary disciplinarian in the
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home setting and presenting with a dominating and authoritative parenting style. In regards to
John’s relationship with his father, Ms. Doe verbalized a positive relationship between the two
and denied any difficulties or challenges to their relationship, which was a contrast from what
was reported by John. In addition, Ms. Doe had a difficult time reporting particular information
in regards to John’s early years such as his birth weight and inches. At the time of intake, there
was no reported family history of suicide, drug, alcohol or incarceration as well as no reported
recent grief and loss that would contribute to John’s negative displayed behaviors.
Medical Profile:
Per Ms. Doe, John does not experience any medical conditions or problems.
Developmental History:
Per Ms. Doe, John was born at full term through vaginal delivery weighing four pounds and
eight ounces at a length of sixteen inches. Ms. Doe had trouble remembering John’s birth weight
and length. She reported no complications during or immediately after her pregnancy despite
John’s low birth weight. She indicated that John was a quiet baby who ate a lot of food.
Furthermore, Ms. Doe reported that John met all milestones at the expected times including
talking by the age of nine months and walking at one year of age.
Mental Health History/Hospitalizations:
Per Ms. Doe, John has been diagnosed with Attention-Deficit/Hyperactivity Disorder, at a
private outpatient practice in 2008 or 2009. Per Ms. Doe, in September 2009, John was
prescribed Adderall 10 mg by Dr. Jones to treat his Bipolar Disorder. In December of 2009, Ms.
Doe reported that his doctor took John off of his medication regime. Ms. Doe reported that John
is currently not prescribed any additional medication regime. In addition, John has previously
received Outpatient counseling services through Dr. Jones in Virginia Beach
Mental Status Profile:
John was oriented to person, place, time, and situation at the time of the intake. He presented as a
well-dressed individual exhibiting appropriate personal hygiene. John appeared his stated age.
He was very well-spoken, able to describe antecedents and consequences to situations at a higher
than expected at his age. He maintained appropriate eye contact throughout the session,
responding spontaneously to the clinician’s inquiries. He exhibited a calm affect throughout the
session.
Drug and Alcohol Profile:
Per Ms. Doe, John has no history of drug or alcohol use. However upon meeting with John
individually, John disclosed a history of marijuana and alcohol abuse beginning in 2010. Per
John, he began drinking alcohol in 2010 in order to achieve peer acceptance as well as to “relate
to my dad.” According to John he progressed to marijuana usage 1 year later and has most
recently been abusing “woohs” which upon clarification from assessor were identified by John as
marijuana laced with powder cocaine. At time of assessment John disclosed that he uses this
mixture of substance on average of 4-5x per week and currently consumes alcohol 1-2x per
week. He reported drinking 2-3 beers per sitting whenever he consumes alcohol which he obtains
by paying older adults to purchase on his behalf. Per John, he will often stand in from of
convenience stores for hours waiting for someone to purchase alcohol for him. With regard to his
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marijuana and cocaine usage, John reports mixing 15$ worth of marijuana with 10$ worth of
cocaine “that will put me right for a while.”At time of assessment John denied any symptoms
indicative of withdrawal, however he did acknowledge increased ability to use more of his
substances of choice over time, continued use of each substance despite its self reported negative
effect on his mood and ability to function in the school setting as well as cravings to use each of
the substances on a regular basis.
Due to John’s age and self-disclosure of drug usage, a release of information was obtained for
Mrs. Doe to continue to participate in the assessment process with John. John has requested that
his substance usage not be disclosed to his mother however he did consent to her participating in
the assessment interview and contacting the agency regarding his appointment schedule once
services are initiated.
Social/Recreational/Community:
Per Ms. Doe, John has been involved in physical altercations in the community setting as a result
of his inability to respond to challenging circumstances. Per Ms. Doe, John is primarily involved
in verbal altercations with peers as a result of his inability to manage his reactive aggressive
behaviors (i.e. being called fat, so he will scream and yell or assault a peer). At the time of
intake, Ms. Doe reported John being enrolled in sports throughout the year in an effort to
appropriately exert his excess energy.
Educational/Vocational Status:
John is a regular education 9th grader currently enrolled at S.W High School and has difficulty
sustaining and maintaining attention and concentration, completing assignments when due,
interacting appropriately with peers in the classroom, and disrespecting teachers and authority
figures. In regards to John’s behaviors in the school environment, John’s teachers reported that
he becomes angered in an intense and sudden manner often overreacting to peers and adults.
John was reported to require more time to “cool down” after becoming angry which often
interferes with completion of his assignments. His attention seeking behaviors in the school has
become a problem as he seeks “special treatment” from his teachers. John is also frequently
disrespectful toward authority figures when his behaviors are corrected. For example, a teacher
told John that his behavior was inappropriate and he would receive a signature and his response
was “So… get out of my face”. Furthermore, John’s advanced age and cognitive development
places him at an advantage in comparison to his peers. According to teachers, John uses this
advantage to antagonize his peers, which leads to aggressive interactions. At the time of intake,
John was observed by examiner intimidating and attempting to assault a smaller peer by
dropping his books onto the ground, pulling his pants up, invading the personal space of the peer
(i.e. his nose touched the cheek of the peer) and verbally threatening the personal safety of the
peer (i.e. I’m going to jack you up, and punch you in your face) after the peer bumped into him
in line. This incident was interrupted by examiner who provided verbal and physical intervention
to stabilize client.
Legal Status:
Per Ms. Doe, John does not have any previous or current involvement in the legal system.
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Resources and Strengths:
Per Ms. Doe, John has many strengths including that he is very intelligent and competitive.
Diagnosis (provisional):
Axis I: ____________________________________________________
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Axis II: V71.09 No diagnosis
Axis III: none reported
Axis IV: Problems with primary support group, Educational problems
Axis V: GAF = 51
Recommended Treatment Goals:
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Clinical Summary and Diagnosis: To be completed by Licensed Staff
Respectfully Submitted,
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Staff Evaluator
Tasks:
- Identify 3 session goals you would like to accomplish with this client. Why did you choose these particular goals for John?
- For your identified goals, identify two strategies you would implement with this client.
- What are some resources that may be helpful in assisting John to meet these goals?
- Reply to two learning team members and provide feedback about their goals- identify other goals and strategies that you think they missed!
