RUNNING HEAD: BIOPSYCHOSOCIAL ASSESSMENT

Shellisa Mitchell
Student ID: ft0464
Wayne State University
SW 3020
Professor Schropshire
7/23/15

Demographic information

BIOPSYCHOSOCIAL ASSESSMENT PT. B

Name: Johanna Thomas

Address: 234 Rosendale Dr.
Kingstown, NY
10001
Phone: 212-443-7768
Email: Jothomas@yahoo.com

Date of Birth: 6/23 /81

Age: 33
Sex: Female
Ethnicity: African American
Date of Interview: 7/16/15

Intake Clinician: Shellisa Mitchell

History of Present Problem
Johanna Thomas (pseudonym) is a thirty-three-year-old single-parent African American female.
Her boyfriend left her for a younger woman, and she currently lives with her parents and her
three children (two girls one and three years old, one male five years old) in parents home. She
is currently unemployed due to her drug usage of four years. Since her boyfriend of nine years
left, she has been faced with some struggles. Parents have to threaten to kick her out, but they are
willing to take care of her children. Ms. Thomas is coming to see a social worker in regards to
homelessness, depression, and substance abuse.
Family of Origin History
Ms. Thomas mother Cecilia was thirty-two years old, and father Bob was thirty-five years old
and when they got married. Mother, a homemaker, and father, worked at a steel plant. The
parents planned to four children, but the fifth (Johanna) was accidental. Currently, her mother is
six-five, and father is six-eight. While the client lived at home with parents, they did not
celebrate non-Muslim holidays because they are Muslims and only celebrate the major Islamic
festivals Eid al-Fitr, Eid al-Adha. As a result of not celebrating American holidays, the
atmosphere in the home was stressful because Johanna wanted to celebrate at least Christmas and
her birthday like her American friends. Her parents had little education, and siblings were very
educated with college degrees. The parents health is overall weak due to poor dieting and
exercise. Mother has Diabetes, high blood pressure, and obesity. The father has congested heart
failure and kidney failure. Grandfather was a drug addicted and grandmother had schizophrenia.
The concept of death is painful and heartbreaking, but they encourage the dying person to
commit and stay faithful to Allah. Johanna expresses there was no sexual abuse, but there was
physical and emotional abuse. She felt sheltered and isolated from friends and society norms.
However, if traditions were violated, she would be punished for her sins to Allah.
Developmental History
Johanna Thomas mother did a full nine months of pregnancy and as a baby she weighed eight lbs
Three ounces; She had a vaginal delivery and very painful which lasted five hours in labor.
Johanna stayed additional three days in the hospital because she swelled her mother fluid during
delivery. She was bottle fed and at two years old she was weaned; Johanna Thomas
developmental milestones included walking at twelve months, talking at ten months old, and
potty trained at four years old. Johanna Thomas had no developmental delays or advanced
developmental issues.
Health History

BIOPSYCHOSOCIAL ASSESSMENT PT. B

Johanna Thomas was healthy at birth; she experienced different childhood illnesses which were
Measles, Chicken Pox, and Asthma. Also, she had a history of gonorrhea and trichomonas. She
had no childhood surgeries or chronic diseases. She broke her leg and had back issues as a result
of playing softball at sixteen years old. As an adult, she has Diabetes and always experienced
weight issues. Johanna mother has Diabetes and is obese. She is experiencing back issues, and
can no longer work because of the excruciating pain. The mother also has high blood pressure
and father has kidney failure and congested heart failure. Johanna had her first menses at age
twelve years old. She is currently taking insulin for her Diabetes and Vicodin and OxyContin for
her back pain.
Relationship/Sexual History
Ms. Thomas had great childhood friends for over twenty years they were supportive of her and
encouraged her to get off drugs. They were exhausted with providing help for Johanna because
noncompliance to treatments. She presently has no current friendships due to her drug use. She
began dating at thirteen years old and her preference is men. Johannas first sexual experience
was at fourteen years old and enjoys having sex and orgasms since that time. She is currently
having sex with random partners with no condoms or birth control. She had a history of
gonorrhea and trichomonas.
Family of Creation History
Johanna Thomas is not currently in a committed relationship and never been married. She was in
a committed relationship with Tom, her ex-boyfriend for nine years. They have three children,
two females Susan one-year-old and Johanna 3 years old, one male Tommy five years old. The
relationship between them was relatively good and then became bad when Johannas drug
addiction got worse. She was on prescription drugs and Tom was helping through it because he
knew the nature of her severe back pain. However, Johanna started using heroin after she had
first daughter Johanna three years ago, and drugs caused the problems in the committed
relationship, and the couple broke up. Johanna and Tom were great parents and loved their
children. As all the turmoil began, the children were always with Johannas parents. Ms. Thomas
drug usage caused problems where she could not attend to her children. She could not function at
work as a substance abuse counselor because she was getting high all the time. Ms. Thomas exboyfriend worked as a licensed mechanic at an auto shop. They both received their diplomas and
had educational trades. Both parents were excited planned pregnancies. The reason Ms. Thomas
wanted children because she felt comfortable and secure in her relationship. She always wanted
children because her parents accidentally had her. She wanted to be a better parent then her
parents. However, she did the opposite and neglected them.
Substance Use/Abuse History
Ms. Thomas uses prescription drugs methadone, Vicodin, and OxyContin a way to get high. She
also is a heroin addict. Ms. Thomas first used the substance at sixteen years old when she broke
her leg and injured her back playing softball. The doctor prescribed pain medication OxyContin
and Vicodin. She had an addiction to prescription pain medication for seventeen years and took
up to seven pills a day. She has used heroin for three years and currently uses excessive amounts
of heroin every day. She smokes cigarettes to calm her nerves and urges because of her
depression. Ms. Thomas parents admitted her to the ER twice due to drug overdoses. The
hospital doctor and social worker petitioned her to Gateway Rehab and Treatment Center for

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help, and she was non-compliant. Ms. Thomas was upset and returned to parents house, and she
repeated the same steps. The second time she was admitted to the hospital, she petitioned to
Caring Hands Rehab and Treatment Center. She was compliant this time because she wanted to
do better for her children and completed a six-month program. However, she relapsed after her
boyfriend came back in the picture trying to take full custody of their three children. Moreover,
this caused an enormous part of her failure in treatment progression.
Mental Health History:
Johanna Thomas has no mental health issues.
Military History
Johanna Thomas has never been in the military.
Financial History
Johanna Thomas family struggled throughout the years of her childhood. The mother never had a
job, but she was creative and made her specialty pies. She sold the pies $4.50 to the community
to help contribute to the household. Johannas father worked very hard to support the family at a
steel factory and made four hundred dollars every two weeks with no saving account. However,
Johanna had a trade position before she got on drugs. She worked as a substance abuse counselor
that paid twelve dollars per hour, and her boyfriend worked at an Auto shop where he was a
mechanic that made a good income. She is currently unemployed with no income and needs
disability for her back issues.
Legal history
Ms. Thomas experienced a possession of drug infraction, and she was given probation for ninety
days but currently is discharged off as November 2012. She was arrested two times for domestic
violence and one time for possession of drugs in 2012.
Immigration issues
She has no immigration issues.

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Summary of the Problem

Johanna Thomas is a thirty-three-year-old single-parent African American female. She is
unemployed and depressed. As a result, her boyfriend of nine years left her and their three
children to stay with her parents. Her parents are willing to assists with the children, but they are
threatening to kick her out. She has a substance abuse addiction for four years, and she is coming
to see a social worker in regards to homelessness, depression, and substance abuse.
Treatment Plan
First, I went over alternatives with Ms. Thomas and told her resolutions starts with a
change in herself. I looked at her attentively, and I encouraged her to pursue these realistic
alternatives: you can get help with your substance abuse, join a support group, and also talk with
a spiritual leader. Additionally, I encouraged Ms. Thomas to call her friends and family because
they were so supportive of her from the beginning of her struggles. I am implementing a
treatment plan to assist Ms. Thomas in finding employment; she will actively search each day
and apply for job opportunities. I referred her to temporally housing at The Women shelter for
mothers for ninety days. However, after ninety days, she will apply for permanent housing
through section eight. She must attend rehab for substance abuse at Brighton House twice a week
for ninety days. She will attend a support group once a week for sixteen weeks. She was
encouraged to do breathing exercises to reduce her stress from being depressed about her life.
She will report to me once a month for updates and concerns until completion and termination of
services. Ms. Thomas was willing to comply with the terms of the treatment plan and she felt it
was durable and feasible. She was very grateful for the services I provided to her, and she looks
forward to new beginnings in her life and to being a better mother towards her children.

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Goal Setting
I.

Ms. Thomas will ensure the well-being of herself and children.

A. Ms. Thomas will attend substance abuse rehab twice a week for ninety days.
1. Ms. Thomas will see her doctor regularly
2. Ms. Thomas will report her treatment progress to a caseworker.
B. Ms. Thomas will comply with temporarily shelter placement for ninety days.
1. Ms. Thomas will apply for permanent housing.
2. Ms. Thomas will find employment to support their well-being.
I

. Ms. Thomas will reduce depression.

A. Ms. Thomas will report that she has been doing breathing exercises twice a week.
1. Ms. Thomas will go to the park for serenity.
2. Ms. Thomas will walk at the park.
B. Ms. Thomas will attend a support group once a week for sixteen weeks.
1. Ms. Thomas will keep a journal for recording her feelings.
2. Ms. Thomas will share her feelings with the support group.

Contract for Intervention Plan

Client Name:
Johanna Thomas
Description of the Problem: Client seeks a social worker in regards to homelessness,

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depression, and substance abuse.

Primary Goals: Ms. Thomas needs to comply to ensure the well-being for herself and
children. Ms. Thomas needs to comply with counseling or strategies to reduce depression.
We, the undersigned, agree to the objectives in the following plan:
A.
B.
C.
D.

Ms. Thomas will attend substance abuse rehab twice a week for ninety days.
Ms. Thomas will comply with temporarily shelter placement for ninety days
Ms. Thomas will report that she has been doing breathing exercises twice a week.
Ms. Thomas will attend a support group once a week for sixteen weeks.

Johanna Thomas 7/23/15

Ms. Mitchell 7/23/15

References

Kirst-Ashman, Karen K., & Hull, Grafton H., (2012). Understanding Generalist Practice
(7thed.) Chicago, IL: Nelson-Hall.
Mitchell, Shellisa, (2015). Bio-Psychosocial Assessment of Johanna Thomas, SW3020,

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Wayne State University.
Neukrug, E. & Schwitzer A (2006). Skills and Tools for Todays Counselors and
Psychotherapists with DVD Belmont: CA Brooks/Cole, Cengage Learning.