Assessment Report

Demographic Information
Name: Caiyah Martinez DOB: 7-15-2000
Address: 1423 Wooded Acres Dr Age: 20
Stroudsburg, PA Gender: Female
Phone: 862-446-3398 Ethnicity: African American/Black
(Hispanic)
Email: caiyahmartinez1@gmail.com Date of Interview: 10/24/20
Name of Interviewer: Tegann Anderson

Presenting Problem or Reason for Referral

Caiyah Martinez is a 20-year-old African American female of below average height
and thin build but has muscle. She was self-referred to the university’s Counseling
Center for assessment and possible counseling related to high levels of stress,
sadness, and lack of sleep. Ms. Martinez reported that she has been finding going
to sleep at night nearly impossible as she goes to sleep around 6 am every day.
She also has reported not wanting to interact with anybody and strong feelings of
sadness. Ms. Martinez said she also has what she calls “episodes” where she is
feelings on top of the world one week and the next week, she feels like gum stuck
on the bottom of one’s shoe. Ms. Martinez was very open to discussing her
situation and she stated she is willing to do whatever it takes to get her out of the
slums and back into the person she used to be. An assessment was conducted to
determine differential diagnosis and best course of treatment.

Family Background
Ms. Martinez was raised in Stroudsburg, PA. She is the youngest of three children
(which are all girls). She does not technically have full siblings; she has two half-
siblings from her mother’s side and two from her father’s side. Her siblings on her
father’s side do not really get into contact with her. Ms. Martinez is close with the
siblings (Arianna and Dayjia) on her mother’s side because she lived with them.
Her father died when she was only one month (homicide), so she never got to
meet him and was raised by her mother. Her mother was a single parent her
whole life, she got her Associates degree from Berkeley College in Wayne NJ and
is now an administrative assistant. Ms. Martinez described her relationship with
her mother as “not it” meaning it was not a good one. She says they had a good
relationship until she got older and realized her mother was not a human being
with some sense. Her mother has said some very unforgivable and hurtful things
to her as she grew up and now Ms. Martinez does not think she can ever forgive
her. Ms. Martinez also believes she is still not over her father passing so these are
two things that she has as baggage and it will never go away unless she gets
proper counseling, but she will never get proper counseling because she does not
feel “comfortable” with it.
Ms. Martinez reported that she had been ready to go away to college as soon as
she got to high school because she was ready to compete in athletics on the
collegiate level and she wanted to live away from her mother. Her mother
encouraged her to stay in NJ because it “would be cheaper” but Ms. Martinez got
better athletic scholarship offers from colleges outside of NJ than from the ones
that are in NJ. She started college this fall and so far, her grades are good. She
says they are not what she wants them to be, because she has high expectations
for herself, but they are pretty good for a freshman that has all virtual classes and
has to teach herself often. She usually stays in her dorm room and stays to herself
because she is an introvert and that is what she likes. She is uncertain about
returning in the spring semester because of the possibility of getting a roommate
and because of new athletic offers. She says she will just cross that road when it
comes about.

Significant Medical/Counseling History

Ms. Martinez reported that she has been to multiple OB/GYNs and doctors
because she had very painful menstrual cycles. She said this was due to her
having endometriosis but other than this she has never been hospitalized for
anything significant, nor has she had any counseling. Ms. Martinez says she does
not believe in counseling for herself as she does for everyone else.

Substance Use and Abuse

Ms. Martinez stated she has never tried any illegal substances and she only drinks
alcohol on certain occasions, which are usually family gatherings. She has worries
about using drugs because her father died due to a situation involving drugs. She
also is not too fond of alcohol because her mother is a functioning alcoholic, and
she despises the type of person her mother is. Her friends always believe she is
lying about having never smoked or tried any other drugs.

Educational and Vocational History

Ms. Martinez attended public school through the eighth grade. In the eighth
grade she went to a “gifted and talented” school for her academics. For
highschool she went to a vocational school and studied criminal justice because
she wanted to be a CIA Agent in the past. Ms. Martinez said that she was “great”
at completing schoolwork. She loved learning; her favorite subjects were
Mathematics and English. Teachers sometimes had problems with her attitude
when it was a bad day for Ms. Martinez, but when it came to grades and work,
she always went above and beyond.
Ms. Martinez is a first semester psychology major with a double concentration in
counseling and forensics. She said she wanted to add forensic because even
though she does not want to be a CIA Agent anymore, she still likes the criminal
justice aspect. She chose psychology because she has always been the type to
give out advice and counsel friends, and she finds joy in helping people relive their
unspoken pain. She is not really having trouble with the college level academics,
the only thing that changed from high school to now is the workload. Ms.
Martinez says there is nothing she cannot handle though.

The only current employment she reported was being an assistant manager at a
small seafood restaurant. She functioned as an assistant manager, server, and
cashier. She liked working there because it was fun, and it was an easy way to
make money.

Other Pertinent Information

Ms. Martinez reported that she has not been able to fall asleep this semester and
she has felt like she has been “going crazy”. She regularly talks to her high school
guidance counselor who is like her “best friend” and says Mrs. Pinto helps her feel
grounded. She says it might be because of how she stresses and because her
boyfriend calls her late since he is incarcerated. It might be something bad, but
she would not know unless she gets evaluated which she says she “never will get
evaluated” because she might “be put in a nut house.”

Mental Status
Ms. Martinez arrived on time for her appointment and was dressed to impress.
She stated that “you can never be overdressed.” She seems to love fashion. Her
hygiene and grooming were good, it went with her fashionable look. She had
little eye contact, saying it makes her “nervous,” but she was very confident and
lively. Her verbal expression suggested intelligence. No problems with
comprehension or judgment were noted. She did say sometimes she has a bad
memory, but it is “nothing to worry about.” She was oriented to person, place,
and time. She denied experiencing any thinking problems or other psychotic
symptoms. She reported her main concerns were extreme levels of stress and
feelings of depression/ manic episodes that interfered with daily activities of
studying, attending classes, eating, sleeping, and performing well at practice. She
denied any suicidal or homicidal ideation.

Tests Results
The following tests were administered: Shipley Institute for Living Scales, IQ tests
online at IQ.com, Emotional IQ Test, Stress Test, Procrastination Test,
Interpersonal Behavioral Scale (IBI), State-Trait Anxiety Inventory, Beck
Depression Inventory, Myers-Briggs Personality Profile, IPIP-NEO Big 5 Test, Locus
of Control Test, and Incomplete Sentence Blanks.

Measures of intelligence included the Shipley Institute of Living test showed a

Verbal score that converted to a dIQ of 103 and Reasoning dIQ of 112. Her Overall
dIQ was 109. These scores all fall in the average range. Ms. Martinez’s score on
the IQ.com test was 126, which is in the above average range. Ms. Martinez said
she did not feel confident about the accuracy this test because she “does not
trust IQ tests validity.” Emotional intelligence is understanding, using, and
managing your emotions in positive ways in order to relieve stress, communicate,
empathize, overcome challenges, and defuse conflict. On the emotional IQ test,
she scored an 80 which is less that average; showing that she may not know how
to manage her emotions. It is most likely the stress part because she did say she is
“always stressing, about nothing.”
Overall, the academic and cognitive tests do not indicate any significant leaning
difficulties that might be impairing her school performance.
The Stress Test results were really above average. She scored an 82 while the
average range went from 51 to 76. She indicated she was experiencing stress
from a wide variety of factors, transferring schools being at the top of the list.
Her score on the Procrastination Test was within the average range based on the
peer group norms. Ms. Martinez indicate that her procrastination is really
nonexistent because she likes when she can relax and not have to worry about
doing something. There was high indication of indirect hostility evident in the
subscale scores of the Interpersonal Behavioral Inventory. She is not highly likely,
but she is definitely not unlikely to act out aggressively. It depends on what the
situation is, as she has said before.
Ms. Martinez scored in the severe range for both current (state) anxiety and
overall (trait) anxiety. Anxiety is a significant concern for her at this moment, but
it seems to be a part of her stress problem. This was evident in her much higher
scores for Neuroticism on the Big 5 Personality measures. That test also
described her as being someone who is easily upset, someone who may be really
depressed, someone who is down to earth, reliable, hardworking, and very
introverted and reserved. The Myers-Briggs Test identified her as an (INTP) who is
described as introverted and shy, intuitive, and someone who thinks and
perceives all the time. On the Beck Depression Inventory, severe symptoms of
depression were suggested. She has stated before she thinks she has depression,
but she will not get checked because they will “just give her medication as if she
was a lab rat.”

Ms. Martinez’s Locus of Control test was above average. This score indicated that
she has a fairly strong belief that things are beyond her control, like things are
because of fate. Her incomplete sentence blank responses were fairly
disconsolate. She stated that she “suffers from depression, it sucks.” She stated
that “I am very worried about my mental health.’ She also stated, “people are
scary because you never know if they are truly genuine.” According to the
responses, it seems that her niece, nephew, and Eminem makes her most joyous.

Diagnostic Impressions
Depression
Anxiety/ Stress
Insomnia

Summary and Conclusions

Ms. Martinez is a first semester freshmen who arrived at college August 2020 on
an athletic scholarship. Her first semester is almost over, and it is going well for
her in terms of grades and completing work. She has experienced a few
depressive mood swings and has had trouble sleeping and eating. She has always
been independent, and she likes that. Ms. Martinez has not had to be treated for
any mental health issues. The only reason for having doctor evaluation is when
she found out about having endometriosis.
Testing showed that Ms. Martinez is very intelligent and showed no evidence of
learning disorders, so she is capable of college level work. However, she may lack
particular skills needed for completing work that she does not want to do,
especially when she gets in an “I hate everything” mood as she called it.

Ms. Martinez is reporting a high degree of depression and stress. This is leading to
more avoidance behaviors. She seems to lack the confidence needed to look into
receiving appropriate sources of support. She does not appear interested any
time soon in doing so either. She would rather “thug it out” as she calls it. This will
not affect her road to success though, this is just a bump in the road for her.

Recommendations
1. Individual counseling to build coping strategies for managing depression
2. Stress management training
3. See a physician regarding sleeping medicine

_________________________________
Tegann Anderson