INTAKE REPORT

YOUR NAME: Brianna Kilborn, Ph.D.

CLIENTS NAME: Gwen Cummings

CLIENTS APPROXIMATE AGE: 30

IDENTIFYING INFORMATION AND REFERRAL STATEMENT

Gwen Cummings is a 30 year old, who is recently single. She is a New York journalist.
She had previously went to a twenty-eight day rehabilitation program.

She was referred to us by Serenity Glen Rehabilitation Center. She was a patient here
for twenty-eight days, and they recommended her to us because she is still at-risk for
using. The rehab helped her for a little while, but then she started drinking again.

The date of her first visit was September 28, 2000.

PRESENTING COMPLAINT:

Gwen got sent to a twenty-eight day rehab because she crashed a limousine, that she
stole from her sisters wedding, while intoxicated. She did not chose to go to rehab and
if she didnt crash she would still be drinking and using. Her drug of choice is Vicodin
which she claims is for her back pain.

Gwen eventually began to appreciate rehab about halfway through which made her
want to get help. Once she left rehab she was sober for a while, but she is starting to
get temptations where she wants to drink and use. One thing Gwen got to help was
smoking cigarettes, but now this is a new addiction to overcome her alcohol abuse.

Gwen may be at risk for an overdose, however she is not suicidal.

HISTORY OF PRESENTING COMPLAINT:

(a) Onset - Gwen starting drinking when she met Jasper. They met at a party and
really hit it off because they were both drunk. He seems to be a bad influence
on her.
Page 2

(b) Identify the precipitation stresses Gwen grew up in foster care because her
mother died when she was a child and her father left them. Not having a proper
family could be the reason for her addiction, which can be looked into further.

(c) Note the clients highest level or adaptive functioning the past year While
Gwen was at rehab she was functioning the best she has in a while. She had
withdrawals at first, but once she found ways to cope with them, she was sober.
She ate lollipops and chewed gum to ease her addictive needs.

(d) Previous conditions, psychiatric hospitalizations and/or treatment which were

similar to or the same as the presenting complaint Gwen has had no other
conditions other than substance abuse. She spent time at a rehabilitation
center, but that has been all the help she has received.

MEDICAL:

No previous medical problems.

Taking Vicodin for back pain, unsure if it is prescribed or not.

PERSONAL HISTORY:

(a) Birth and Infancy: Gwen had a good infancy with her sister, Lily, and her
mother.

(b) Childhood: Gwen was put in the foster care system after her mother died. Her
father was not in the picture so they had to join foster care.

(c) Adolescence: Gwen met Jasper and they fell in love very quickly. They had the
same interest which was partying. He was not a very good influence on her, but
she was having a good time with him.

(d) Present: Gwen is currently living in an apartment on her own. She got fired
from her job due to the incident, and she is searching for a new one. Her sister
is trying to help her out finding a new job. Gwen is currently single because
she broke things off with Jasper.

FAMILY CONSTELLATION:

Lily is Gwens sister, who is also the only member of her family. They are not very
close because of Gwens drinking problem, but Lily wants that to change, and be
Page 3

close with her sister again. Lily is a newlywed and Gwen made it clear that she
doesnt like her husband Andrew.

Gwen didnt grow up with her family. Her mother died when she was young, and
her father left the family.

Jasper was Gwens latest boyfriend. They recently broke up because after rehab
she wanted to start fresh, and needed to get all the toxic people out of her life.
Jasper was a partier just like Gwen, and he seems to be part of the reason she
drinks. He was a bad influence on her. Jasper proposed to Gwen while she was at
rehab, but she didnt say yes nor no. It wasnt until a little later that she turned
him down because she realized he was no good for her.

Eddie Boone is Gwens friend from rehab. They had a good relationship for the
most part. They had a little fight right before Gwen got released, but he apologized
when she was leaving. Eddie was a good friend to Gwen and he taught her many
things.

Andrea was Gwens roommate in rehab. She helped Gwen adjust to rehab, and
helped her through her withdrawals. They both helped each other out. Andrea
started having really bad withdrawals and ended up overdosing right before she
was about to be released. This was eye opening for Gwen.

CLINICAL DESCRIPTIONS, IMPRESSIONS, AND OBSERVATIONS:

(1) Pertinent dynamic factors Gwen may have gone down the path she did due to
not having her parents while growing up. Her mother died when she was young,
and her father walked out on them. Childhood problems are a big causal factor in
substance abuse.
(2) Appraisal of insight and motivation for treatment Gwen did not chose to
receive treatment, but she was sent to rehab because of her accident from driving
under the influence of alcohol. Gwen is also trying to reconnect with her sister and
make a better relationship.
(3) Level of functioning or impairment, including the clients own strengths and
resources Gwen is not a functioning alcoholic. She does not think before she acts
which is what led to the accident. She also ruined her sisters wedding due to
being very intoxicated.

Areas of functioning and/or impairment* should focus on:

(1) Symptomatology Doesnt show many symptoms except for withdrawals while
trying to stay sober.
(2) Productivity went out for fun often before rehab, does not much anymore.
Page 4

(3) Capacity for pleasurable experiences her hobbies included partying before
rehab.
(4) Interpersonal relationships Gwen is hard to become friends with at first, but
after a while she is an easy person to talk to. She made many friends while at
rehab.
(5) Capacity to handle ordinary conflicts and stresses Gwen would drink if
something was wrong and would just push it off as much as she can. She also
does not ask for help. At rehab she was given a sign to wear which said confront
me if I dont ask for help. Her counselor recognized her urge to do everything
herself.

TENTATIVE DIAGNOSIS:

Quinn suffers from substance abuse. Substance abuse involves an excessive use
of a substance resulting in (1) potentially hazardous behavior such as driving while
intoxicated or (2) continued use despite a persistent social, psychological,
occupational, or health problem (Abnormal Psychology, page 369). Gwen crashed
into a house while driving under the influence, which is what brought her to rehab.
Driving while under the influence not only puts the driver in danger, but others
around and on the road.

More specifically, Gwen suffers from alcohol abuse and drug dependency.

INITIAL TREATMENT RECOMMENDATIONS:

The treatment plan for Gwen is to continue with support group, and go back to
rehabilitation (if needed). Gwen is ready to change her ways, and wants to live a
better, healthier life. I am recommending her to go to Alcohol Anonymous meetings
for six months. If this is helping her the most, she will be recommended to
continue going. At six months she will get a six month sober chip which is a great
accomplishment for people, and it keeps them motivated to stay sober. Gwen can
also go to family therapy with Lily to better their relationship. If support groups
and therapy are not helping Gwen stay sober, she will be prescribed Antabuse.

INITIAL PROGNOSIS:

Gwens prognosis is good if she remains going to therapy and AA meetings. The AA
meetings will really help her find the support she needs to stay sober. Without
Jasper in her life anymore, she has a higher chance of staying sober since she isnt
around any other alcoholics.
Page 5

______________________________
Brianna Kilborn, Ph.D.
Clinical Physician