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  DR. Michael Shery, clinical psycholoGY

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Sample Report:

Psychological Assessment: Anger Status and Management

Subject: John Doe 

Date of Report: November 16, 2011

 

Background of Incident Requiring Anger Assessment

The subject worked for several years as a trainer at a large corporation before being laid off. After persistently searching for a job, he finally found steady work as an installer for an insulation contractor which lasted for several years. But the work had dramatically scaled back, until he ended up on unemployment because of the lack of work.

He had then been unemployed for most of 2008 through 2009, getting unemployment compensation but getting no interviews from job applications which was very frustrating for him. He also had some major events coming in the year 2009, that included his oldest son’s graduation from high school.

His family took a long weekend trip to Charleston and also decided to combine a pre-paid family vacation to Disney in Florida with a visit to the subject's mother, who was 90 and going blind. He hadn’t visited her in over 7 years.

In the meantime, his wife and he felt that they could do some major improvements around the house, including landscaping and work on their gazebo and deck. His failure to finish these projects created friction, stress and major arguments.

Subsequently, the subject and his wife had a severe argument, which seemed to mainly settle around a difference of opinion about where to plant a tree. The subject finally refused to plant it. His brother-in-law agreed to do it, to calm things down.

The subject's wife then threatened to cancel the Charleston trip though they finally went at the last minute because of the pre-paid airfare. Unfortunately, they spent 4 days constantly bickering and arguing.

His son graduated from high school in June, further delaying the completion of improvement tasks and the subject decided that his brother in law, who had moved in with them on Dec 08; should finally move and find another place to live.

However, his wife refused, so the subject, himself, asked the brother-in-law to leave on July 09. The subject reports a very unfortunate history of starting and juggling many projects at once, then never finishing any, or at least to his satisfaction.

He reports that his wife subsequently gets angry and that he gets resentful because of never feeling appreciated for what he does. Their arguments then degenerate into name calling, foul language and physical outbursts like throwing things around the house or slamming doors.

His arrest that August occurred after approximately a 3 day onslaught of their arguing and name calling behavior. He was already anxious about a list of things that he promised to complete before they went on their trip to Florida and, further complicating things, their older son and daughter threatened to refuse to go because of all the turmoil.

He reports being extremely stressed out and disappointed, because this family trip to his mother's, because of her advanced age, might possibly their last and he might have to just go alone. Then his wife made the offer that if he finished the list, then they would all still go.

The subject first refused, then relented and grudgingly started working like a “crazy” man until he was exhausted and could do no more while the projects were still incomplete. He gave up and went to bed, planning on going alone on the trip with his youngest son.

He retired for the night and then, at 3AM, 2 hours before he was going to just take his son and go to Florida, his wife came down to the basement where he was sleeping, started arguing and said that his youngest son would not be allowed to go. He then “snapped” and went after her while they were arguing in the basement.

He reported that his intentions were to “spank her like a bratty child” and that the incident progressed from slapping, to kicking, then punching. He ended up chasing her upstairs and the altercation started again; he slapped her, pulled her hair and he reports that she then physically retaliated.

Then in a “defensive move,” he reports, to prevent her from hitting him, that he grabbed her wrist to pull her down, then, her wrist snapped. He reported that initially, he didn’t believe she was seriously hurt.

She then cradled her wrist, then called the police. By the time the police arrived, he reports her being outside, upset, but somewhat calmed down.

The subject reported being very upset that he could possibly have hurt her and let things get so out of control. The police interviewed both of them then called paramedics, with her refusing treatment.

Police arrested and processed him and he was out on bail about 3 hours later. An emergency 72 hour Order of Protection was placed against him.

In the meantime, his wife made arrangements to get to the airport and fly to Florida with her son. The client, amazingly, flew to Florida himself, met them at the airport and they went together to see his family.

That same day she went to an emergency room in Florida and discovered that indeed her wrist was fractured. The three of them, then spent a few days visiting with his mother and sister and spent some time at the beach. His two older kids flew down later, went to Disney World, then flew home.

He was arrested for assault and battery, but the legal proceedings stretched out for an entire year. He was finally assigned a public defender and the case was plea bargained down to a simple misdemeanor; he was charged with a $5 fine and one year of probation.

He made about 5 or 6 court appearances during that year, though his wife did not attend any of them. During that time, on his own, he reports getting some interventions with doctors, then a psychiatrist and psychologist.

That is when he had undergone a first anger assessment with which he was dissatisfied because he reports that the examiner had confused his case with someone else's. He subsequently refused to pay for it before it was completed and subsequently contacted this examiner.

The following are the findings of that assessment.

Structure of Assessment:The assessment consisted of 4 in-office interviews with the subject, 1 with his wife and administration of the Personality Assessment Inventory (PAI), the Millon Clinical Inventory III, the Brown ADD Scales and the Aggression Questionnaire.

Mental Status: During the interviews the subject was alert, oriented to person, place, time and situation. His levels of judgment and insight were sound, as was his ability to remember and concentrate. He showed no signs of disordered thought processes and his manifested affect was appropriate to the content of his verbalizations. Intellectually he appears to function in the high average to high range and he denies ever having any hallucinations or suicidal or homicidal ideation.

Dysfunctional History of Anger-Related Events: The subject reported no history of bar fights or other anger-triggered situations which caused him significant legal problems. He indicated that his anger is mainly an issue confined to the parameters of wife and family and appears to be aware of the risks of badly managed anger.

Summary of the Subject's Interviews: His Understanding of Anger and its Impact: Heviews himself as frustrated and very troubled by his lack of employment and the periodic severe arguments which occur between him and his wife. Also, he seems very troubled by his inability to complete tasks and finish household projects to which he commits himself. He is aware that anger, unchecked, can have troubling consequences, particularly with his wife, and is motivated to improve the way he interacts with her when frustrated.

Summary of his Wife's Interview: Her Understanding of Anger and its Impact: She alsoviews herself as frustrated but not excessively troubled by his lack of employment. She reports that the periodic severe arguments which occur between them, primarily are triggered by his inability to complete tasks and finish household projects in a timely manner.

She also appears aware that anger, unchecked, can have troubling consequences in their marriage and is very confused about the role his ADHD may play in his agitation and failure to complete tasks. Also, she is sorry she reported the incident necessitating this report because she feels the legal process has not been helpful.

SYMPTOM SCREEN

The last physical examination the client had was more than a year ago; he recalls having no problems at that time. The client's last dental exam was within the last six months. He is currently having problems with his teeth.

He reports having had surgery performed more than once. His family history includes heart trouble or stroke, high blood pressure, and cancer.

He believes that he is mainly in good health with the presence of some minor problems.

He is near-sighted and far-sighted. His history also includes high blood pressure and a heart murmur. He reports having had prostate problems and has also suffered from arthritis.

The client has recently had a problem with being overweight. He also reports recently experiencing hearing loss, ringing or buzzing in his ears or head, poor equilibrium, memory lapse, poor concentration, and numbness.

In addition, he has experienced heart palpitations and leg cramps that wake him up. He reports urinary urgency and a weakened urine stream. Regarding sexual intercourse, he complains of inhibited arousal/interest.

He reports recently noticing increased dryness of his skin. The client reports that he has recently been troubled by neck pain, back pain, joint pain, muscle cramps, swollen/tender joints, and neck/joint stiffness.

The client currently drinks alcohol several times a month. He usually drinks beer or wine. He does not report any usual diagnostic signs of current pathological alcohol use, and he has not experienced an increase in tolerance over time. No usual diagnostic signs of psychosocial impairment caused by alcohol use were reported.

He does not report any use of unprescribed psychoactive drugs. He has experienced repeated episodes of persistent depressed mood and diminished energy level accompanied by difficulty concentrating, social withdrawal, and irritability.

He indicates that he has experienced repeated episodes of persistent elated mood, increased energy level, racing thoughts, and uncontrollable talkativeness accompanied by heavy spending, increased sex drive, inflated self-confidence, and irritability.

He does not report having experienced thought broadcasting, thought insertion, thought withdrawal, auditory distortions and hallucinations, grandiose beliefs, persecutory beliefs, or feelings of being controlled.

The client has not experienced anxiety or panic attacks. No phobias were mentioned. He denies having had unwanted, repetitive thoughts or having performed repetitive acts. His current sleep pattern is characterized by waking up too early and having trouble falling back to sleep, excessive daytime somnolence, and feeling unrefreshed by sleep.

MARITAL HISTORY

The client reports his primary sexual orientation to be heterosexual. He is currently married and living with his wife. He reports being married twice. He reports having natural children and a stepchild. He lists his partner's race as white, religion as Protestant, and gender as female.

His partner has a college education in nursing and works full-time in a hospital setting. Their relationship is troubled by problems concerning money, excessive arguing, and domestic chores. The client believes that their relationship suffers from a lack of affection, trust, and time spent together.

EDUCATIONAL HISTORY

He reports that his elementary school performance was usually excellent. In general, he greatly enjoyed elementary school and describes himself as being popular with most schoolmates.

In high school he received mostly B's. His extracurricular activities included athletics and student government. He remembers having difficulty in high school because of problems at home and having to work.

He reports no major antisocial behaviors in high school. The client describes himself as being neither popular nor unpopular with other students and as being neither happy nor unhappy in high school. The client reports graduating from high school, college and having completed all the requirements for a master's degree in education except for the required thesis.

LEGAL HISTORY

The subject reports going through a divorce. He also reports having declared personal bankruptcy and he filed a disability claim based on his having a mood disorder that was denied. He also reports having been charged and convicted of misdemeanor battery with this report being part of the consequences.

There are no other charges pending against him. He has he has never been committed to a psychiatric institution.

Psychiatric and Medical History: The subject reports a previous history of psychiatric evaluation and psychopharmacologic treatment. He has been previously diagnosed as having a mood disorder and ADHD and has been prescribed various medications at various times, including Trileptal, Abilify, Celexa, Lexapro, Strattera, Adderall, Ritalin and Concerta. At the time of this report he has stopped taking all prescribed medications because doubts about their effectiveness, however.

 

Test Findings-Personality Assessment Inventory (PAI)

Clinical Features

The PAI clinical profile is marked by a significant elevation on the DEP scale, indicating that the content tapped by this scale may reflect a particular area of difficulty for the respondent.

The respondent reports a number of difficulties consistent with a significant depressive experience. He is likely to be plagued by thoughts of worthlessness, hopelessness, and personal failure.

He admits openly to feelings of sadness, a loss of interest in normal activities, and a loss of sense of pleasure in things that were previously enjoyed. However, there appear to be relatively few physiological signs of depression.

The respondent describes his thought processes as marked by confusion, distractibility, and difficulty concentrating. He may also have problems communicating clearly with other people because of speech that may tend to be tangential or circumstantial.

According to the respondent’s self-report, he describes NO significant problems in the following areas: antisocial behavior; problems with empathy; undue suspiciousness or hostility; extreme moodiness and impulsivity; unusually elevated mood or heightened activity; marked anxiety; problematic behaviors used to manage anxiety; difficulties with health or physical functioning.

Also, he reports NO significant problems with alcohol or drug abuse or dependence. However, attention should be paid to the possibility of denial of problems with drinking or drug use, as the respondent described certain personality characteristics that are often associated with involvement with alcohol or drugs.

Self-Concept

The self-concept of the respondent appears to involve a generally negative self-evaluation that may vary from states of harsh self-criticism and self-doubt to periods of relative self-confidence and intact self-esteem. This fluctuation is likely to vary as a function of his current circumstances.

During stressful times, he is prone to be self-critical and pessimistic, dwelling on past failures and lost opportunities with considerable uncertainty and indecision about his plans and goals for the future. Given this self-doubt, he tends to blame himself for setbacks and sees any prospects for future success as dependent upon the actions of others.

Interpersonal and Social Environment

The respondent’s interpersonal style seems best characterized as one of autonomy and balance. With both interpersonal scales scoring in the average range, his assertiveness, friendliness, and concern for others is typical for that of normal adults.

He is experiencing notable stress and turmoil in a number of major life areas, including his current unemployment, financial status, and family conflicts. He experiences his level of social support as being somewhat lower than that reported by the average adult.

He has relatively few close relationships outside of his immediate family. Importantly, interventions directed at his problematic relationships (such as those involving family or marital problems) may be important in alleviating this source of stress.

Treatment Considerations

Treatment considerations involve issues that can be important elements in case management and treatment planning. Interpretation is provided for three general areas relevant to treatment: behaviors that may serve as potential treatment complications, motivation for treatment, and aspects of the respondent’s clinical picture that may complicate treatment efforts.

With respect to anger management, the respondent describes himself as being rather impatient and easily irritated. He is relatively quick-tempered at times, and he may be easily provoked by the actions of those around him. However, he does not report any specific aggressive behaviors that are recurrent problems for him.

The respondent is not reporting distress from thoughts of self-harm. The respondent’s interest in and motivation for treatment is typical of individuals being seen in treatment settings, and he appears more motivated for treatment than adults who are not being seen in a therapeutic setting.

His responses suggest an acknowledgment of important problems and the perception of a need for help in dealing with these problems. He reports a positive attitude towards the possibility of personal change, the value of therapy, and the importance of personal responsibility.

In addition, he reports a number of other strengths that are positive indications for a relatively smooth treatment process and a reasonably good prognosis.

 

MCMI-III

Millon Clinical Multiaxial Inventory-III

 

CAPSULE SUMMARY

Interpretive Considerations

These self-reported difficulties, which have occurred for an undetermined period of time, may take the form of an Axis I disorder.

Profile Severity

On the basis of the test data (assuming denial is not present), it may be reasonable to assume that the patient is exhibiting psychological dysfunction of mild to moderate severity.

Therapeutic Considerations

This patient often feels misunderstood, tense, and depressed. Overly sensitive to how others react to him, he frequently overreacts, withdrawing or displaying self-derogating attitudes.

He may be erratic in relating to therapists and may have been disappointed in or ambivalent about plans for his treatment. Calm expressions of genuine interest and attention may help moderate his discomfort and depressive feelings.

AXIS II: PERSONALITY PATTERNS

The following paragraphs refer to those enduring and pervasive personality traits that underlie this man's emotional, cognitive, and interpersonal difficulties. Rather than focus on the largely transitory symptoms that make up Axis I clinical syndromes, this section concentrates on his more habitual and maladaptive methods of relating, behaving, thinking, and feeling.

The profile on the MCMI-III suggests that this man may be characterized as socially anxious, emotionally downcast, and self-sacrificing. He is likely to assume a weak and passive role in close relationships and repeatedly places himself in inferior or demeaning positions.

Most notable are a lack of confidence and an avoidance of events that test his adequacy. Unusually insecure, he may permit others to be exploitive and mistreating, often courting unjust criticism or blame.

Despite his self-defeating style, he may resent those that he allows to exploit him because they are often abusive and inconsiderate despite his efforts to please them. Occasionally, his resentment may surface into outbursts of anger.

Because he believes his security is threatened by expressions of anger, he usually discharges his resentment in an indirect manner. He either withdraws from what he experiences as abusive relationships or convinces himself that he deserves to be shamed and debased.

His underlying tension and emotional dysphoria are usually present in disturbing mixtures of anxiety, dejection, and guilt.

His insecurity and his fear of being left to his own devices appear to underlie his self-sacrificing and self-abasing behavior. Between periods of quiet withdrawal and occasional negativism, he may be overly conciliatory and even ingratiating. He hopes to evoke support and protection by acting weak, by denying himself, by expressing self-doubt, by communicating needs for assurance and direction, and by displaying a desire to submit and comply.

Moreover, he hopes to avoid severe forms of humiliation and rejection by submerging his individuality, by subordinating his personal desires, and by submitting at times to abuse and intimidation. This man's reported feelings of apathy and worthlessness and his tendency to succumb easily to physical exhaustion and illness may reflect a persistent and chronic depression.

Simple responsibilities may demand more energy than he can muster, and he may describe life as painfully empty. By withdrawing, seeing himself as deserving to suffer, permitting exploitation, and undermining his occasional good fortune, he precludes new, potentially favorable experiences for reorienting his life.

GROSSMAN PERSONALITY FACET SCALES

The Grossman facet scales are designed to aid in the interpretation of elevations on the Clinical Personality Patterns and Severe Personality Pathology scales by helping to pinpoint the specific personality processes (e.g., self-image, interpersonal relations) that underlie overall scale elevations.

A careful analysis of this patient's facet scale scores suggests that the following characteristics are among his most prominent personality features. He has few close relationships, minimal "human" interests, and limited deep personal involvement in his family relationships.

An inability to engage in the give-and-take of deeper relationships may be observed. He can be rather vague and disengaged from group interactions, appearing to be involved in his own preoccupations.

It is difficult for him to enthusiastically mix with others even during pleasant social activities. Also salient is his characterological inclination to be mournful, joyless, tearful, and morose, an emotional disposition that is intensified by his tendency to be worrisome, pessimistic, and guilt-ridden.

His interest in life is diminished, and he has little appetite for joy and closeness. He may go through the motions of relating to others, eating, having sex, and even playing, but he does so with little enthusiasm.

His temperamentally based inertia and sadness may undermine whatever capacity he may have to enjoy life. Early treatment efforts are likely to produce optimal results if they are oriented toward modifying the personality features just described.

AXIS I: CLINICAL SYNDROMES

The features and dynamics of the following Axis I clinical syndromes appear worthy of description and analysis. They may arise in response to external precipitants but are likely to reflect and accentuate several of the more enduring and pervasive aspects of this man's basic personality makeup.

A pattern of dysthymia is an integral part of this man's characterological structure. He exhibits a cluster of chronic general traits in which feelings of uselessness, dejection, pessimism, and discouragement are intrinsic components.

Preoccupation with concerns over his social adequacy and personal worthiness, pervasive self-doubts, and feelings of guilt are all part of a constellation of long-term features of this man's psychological makeup. His reports of feeling aggrieved and mistreated are consistent with his belief that he deserves the anguish and abuse he experiences.

Consonant with his intrapsychic dynamics, he may regularly set in motion conditions that further aggravate his misery.

NOTEWORTHY RESPONSES

The client answered the following statements in the direction noted in parentheses. These items suggest specific problem areas that any treating clinician should investigate.

 

Health Preoccupation

37. I very often lose my ability to feel any sensations in parts of my body. (True)

130. I don't have the energy to concentrate on my everyday responsibilities anymore. (True)

 

Interpersonal Alienation

27. When I have a choice, I prefer to do things alone. (True)

92. I'm alone most of the time and I prefer it that way. (True)

161. I seem to create situations with others in which I get hurt or feel rejected. (True)

165. Other than my family, I have no close friends. (True)

174. Although I'm afraid to make friendships, I wish I had more than I do. (True)

 

Emotional Dyscontrol

People have said in the past that I became too interested and too excited about too many things.(True)

Sometimes I can be pretty rough and mean in my relations with my family. (True)

 

Self-Destructive Potential

24. I began to feel like a failure some years ago. (True)

112. I have been downhearted and sad much of my life since I was quite young. (True)

142. I frequently feel there's nothing inside me, like I'm empty and hollow. (True)

 

Childhood Abuse

I'm ashamed of some of the abuses I suffered when I was young. (True)

 

POSSIBLE DIAGNOSES

According to the MCMI III:

Axis I: Clinical Syndrome

The major complaints and behaviors of the patient parallel the following Axis I diagnoses, listed in order of their clinical significance and salience.

300.40- Dysthymic Disorder

AXIS II: Personality configuration composed of the following:

Self-defeating Personality Traits; Depressive Personality Traits; Schizoid Personality Features; and Borderline Personality Features

The clinical syndromes described previously tend to be relatively transient, waxing and waning in their prominence and intensity depending on the presence of environmental stress.

Axis IV: Psychosocial and Environmental Problems

The following problems may be complicating or exacerbating his present emotional state. They are listed in order of importance: unemployment and dysfunctional marriage

According to the PAI:

Listed below are DSM-IV diagnostic possibilities suggested by the configuration of PAI scale scores.

Axis I Diagnostic Considerations:

300.4-Dysthymic Disorder

Axis I Rule Out:

296.20 Major Depressive Disorder, Single Episode, Unspecified

296.89 Bipolar II Disorder

 

Deferred on Axis II

 

According to Brown ADD Scales, the subject has a compelling case of ADHD making it very difficult for him to remember tasks, organize, finish projects in a timely way and focus and sustain required attention.

Axis I- 314.01- Attention Deficit /Hyperactivity Disorder Predominantly Combined Type

According to the Aggression Questionnaire:

The subject scored in the high average range in his total score on this measure, suggesting a tendency to have more difficulty than many in his age range in expressing anger functionally-Result:Difficulty Expressing Anger.

The sub-scores follow: The subject scored high on the Physical Aggression Scale which would suggest that he has an increased pre-disposition to engage in physical aggression when agitated.

Result: This suggests that the subject may find it difficult to control his impulse to be physically combative when very angry.

He scored in the average range on the Verbal Aggression Scale, suggesting a pre-disposition to be as verbally argumentative as most people in his age range when facing obstacles.

Result: He scores in the high average range on the Anger Scale, suggesting that he is likely to experience more hard-to-control irritability or frustration than others his age.

This suggests he is deficient in the number of anger management skills at his disposal and would benefit from expanding his repertoire of anger management coping strategies.

The Indirect Aggression Scalemeasures his tendency to express aggression indirectly rather than appropriately. His score is in the high average range suggesting a reluctance on his part to express aggressive feelings assertively.

Result: He is more likely than others his age to use counter-productive means such as passive-aggressiveness to express anger.Possible Diagnoses: 312.35- Isolated Explosive Disorder

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Diagnoses Suggested by the Results

Clinical syndromes, based on complete evaluation by examiner are as follows: .

Axis I- 314.01- Attention Deficit /Hyperactivity Disorder Predominantly Combined Type; 300.4-Dysthymic Disorder;

312.35- Isolated Explosive Disorder

Axis I Rule Out: 296.89-Bipolar II Disorder

Axis II: Self-defeating Personality Traits, Depressive Personality Traits, Schizoid Personality Features, and Borderline Personality Features.

Is any treatment or further evaluation needed? Yes / Treatment needs: anger management; further assessment regarding the presence of bipolar disorder; marital dysfunction; ADHD

It is recommended that the subject and his wife receive treatment on a weekly basis (once or twice per week) to discuss their stressors, frustrations, impact of the subject's ADHD on their relationship and the effectiveness of their problem solving methods until they are released by their therapist. If his wife refuses to attend marital therapy, then the subject should receive the same treatment, himself, on an individual basis.

The patient should consult a psychiatrist to evaluate his need for psychotropic medication. If psychopharmacologic treatment is indicated, then the subject should be required to receive it, consulting with his psychiatrist, on an ongoing basis until released from treatment with a desired outcome.

Need for Court Supervision: As a result of this assessment it is recommended that if the subject complies with the above treatment recommendations, it is unnecessary for him to receive any other ongoing court supervision.

I appreciate working with the court system and Mr John Doe. I look forward to assisting with any other assessments or consulting of a psychological nature, should the need arise.

 


 

Respectfully Submitted,_________________________;________

Dr. Michael Shery, Psychologist Date

 

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