Social histories are prepared to paint a comprehensive picture of a client’s situation and
relevant information. This information may come from referral sources, other providers,
and the client. For this assignment, you will be drafting a social history for your client,
Mr. Brown, from the Case Vignette.
Instructions:
Apply the information provided in the Case Vignette and prepare a social history that
addresses the following:
• Client information
• Presenting Problem
• Referral (Including source and reason)
• Medical History
• Personal/Family History
• Education
• Work History
• Personality and Habits
Requirements:
• Submit a Word document that includes a title page.
• Be sure to address each section fully. Each area of information can be broken
into sub-sections, listed with the appropriate heading.
• This is a professional report and should use formal language, complete
sentences, proper grammar and appropriate sentence structure.

 

 

Sample Answer

Sample Answer

Social History: Mr. Brown
Client Information
Name: Mr. Brown
Age: 45
Gender: Male
Marital Status: Divorced
Ethnicity: Caucasian
Religion: None specified
Sexual Orientation: Heterosexual
Presenting Problem
Mr. Brown has sought therapy due to feelings of depression and anxiety. He reports experiencing low mood, loss of interest in activities he once enjoyed, difficulty concentrating, and frequent worry about his financial situation. These symptoms have been present for the past six months and have significantly impacted his daily functioning.

Referral
Mr. Brown was referred to therapy by his primary care physician, Dr. Smith. Dr. Smith became concerned about Mr. Brown’s mental health during a routine check-up. Mr. Brown expressed his concerns about his emotional well-being, and Dr. Smith recommended seeking therapy to address these issues.

Medical History
General Health: Mr. Brown reports being in good overall health.
Chronic Conditions: None reported.
Medications: Mr. Brown takes medication for high blood pressure.
Allergies: None reported.
Hospitalizations/Surgeries: No significant hospitalizations or surgeries.
Personal/Family History
Family Background: Mr. Brown was born and raised in a small town in the Midwest. He is the youngest of three siblings. His parents divorced when he was 10 years old, which had a significant impact on his upbringing.
Childhood: Mr. Brown described his childhood as challenging due to the divorce of his parents. He had a strained relationship with his father and experienced financial hardships.
Relationships: Mr. Brown got married at the age of 25 but got divorced after 15 years of marriage. He has one child, a daughter aged 18, who lives with her mother.
Support System: Mr. Brown maintains a close relationship with his daughter and occasionally meets with friends for social activities.
Education
Highest Level of Education: Mr. Brown completed high school but did not pursue any higher education.
Academic Performance: Mr. Brown was an average student throughout his school years and did not participate in extracurricular activities.
Vocational Training: None reported.
Work History
Occupation: Mr. Brown has been working as a sales representative for a pharmaceutical company for the past 20 years.
Job Satisfaction: Mr. Brown reports feeling dissatisfied with his current job due to high levels of stress, long working hours, and limited opportunities for growth.
Previous Employment: Before joining the pharmaceutical company, Mr. Brown worked in retail sales for five years.
Personality and Habits
Personality Traits: Mr. Brown is described as introverted, detail-oriented, and reliable.
Coping Mechanisms: Mr. Brown tends to withdraw from social activities when he feels overwhelmed. He also engages in regular exercise as a means of stress relief.
Substance Use: Mr. Brown does not report any history of substance abuse or dependence.
Hobbies and Interests: Mr. Brown enjoys reading, gardening, and playing the guitar in his free time.

In conclusion, this social history provides a comprehensive understanding of Mr. Brown’s background, presenting problem, referral source, medical history, personal/family history, education, work history, and personality traits. This information will be crucial in guiding therapeutic interventions to address his current mental health concerns and support his overall well-being.

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