Appearance? Attitude? Motor Activity? Affect? Mood? Speech? Thought Process? Thought Content? Perception? Orien

Instructions

This assignment will give students an opportunity to integrate their learning from the class and develop social work practice skills.This assignment will focus on conduction of a comprehensive bio-psycho-social assessment using cultural, ecological, transactional, and developmental frameworks and current technologies that focus on needs, strengths, capacities, assets, and resources of an individual client in relation to his/her/their broader environments. 

Each student will write their assessment based on a movie character. The movie character chosen is up to each student; it can be any movie. You are welcome to reach out to the professor for approval of the movie and character; you should consider the assignment and the need to offer some a diagnosis as a part of the movie selection. Please make sure you watch the movie with the intention of completing this assessment; you may need to watch the movie several times to gather the information needed for the assessment. If you don’t know something that is crucial to making a diagnosis etc., you can either “make it up” or state that you were unable to gather the information. You can write something like, client was unable or unwilling to discuss this topic and further assessment is needed. 

This paper will be written according to the following outline:

Part I: Identifying Information, Referring Information, and Presenting Problem 

This should be a 1 paragraph introduction that offers a brief overview of these issues; they will be explored in more depth later in the assessment.

· Date, name, age, sex, race, source of income, marital status, living arrangements, etc… 

· Why did the client present to treatment? 

· What issues does the client want to work on versus the social worker? 

· What was the client’s attitude towards the assessment? Who referred the client to treatment and why? 

Part II: Assessment  A. Detailed Explanation of the Presenting Problem 

Explain the reason the client came to see you in detail. Also describe the history of the presenting problem – how did it develop? How long has it been going on? How much is it impacting the client? Is the problem taking place in multiple settings (home, school, work, etc.)? Has the client been to treatment for this problem before? If yes, what was the outcome? If the client has been to therapy for this problem, what did the client like or dislike about the therapy? 

B. Biological Section 

Medical History 

Current physical health medications and doses, are you taking as prescribed, history of surgery, sexual history, allergies?

C. Psychological Section 

a. Psychiatric History 

This includes history of diagnoses, history of therapy or treatment, history of suicidal ideation, history of suicide attempt, history of homicidal ideation and attempts,, history of self-harming behaviors, history of hospitalization, current and past psychiatric medications, is the person taking medication as prescribed, history of abuse. Any history related to suicide or homicide / hospitalization should be detailed. Is there a family history of suicide or psychiatric hospitalization? This section should also include a paragraph about current psychiatric symptoms as well as their frequency and intensity. 

b. Substance Use History 

First use, current use, last use, history of treatment, history of detox symptoms to include blackouts, seizures, family history of treatment, do you smoke, physical disabilities. If someone is currently using substances, be sure to ask how much, how often, and if the person has tried anything to stop or cut back / what has happened when they tried. 

D. Social Section

a. Family Background 

Brief summary of childhood, born and raised, were parents married, with whom did you live growing up, who did you feel closest to, extended family relationships, are there family members you avoid or aren’t speaking to, significant relationships, how many times married/divorced, number of children and ages. How does the client view the family? How does the client perceive the family to view him/her/themselves? 

b. Friendship and Recreation 

What is the client’s friendship circle like? Does the client participate in activities, clubs, groups in the community? Does the client have hobbies? Interests? Travel? 

c. Education and Work History 

This is a summary of the client’s education (did the client graduate high school? Attend college? Graduate with degrees) and summary of relevant employment. Does the client tend to do well in the workplace? Achieve goals? This is also the space to write about a client’s military career, if applicable. If the client has been discharged from the military, it is helpful to note whether that person is eligible for VA Services. 

d. Spiritual and Religious History 

Discussion about the client’s current and past religious affiliation and beliefs. How important are these values/ beliefs to the client? How do they influence the client’s decision making? Does the client belong to a faith community? How would the client like these issues to be incorporated in treatment? 

e.  Cultural Functioning 

Is anything related to culture happening? Languages spoken, immigration status, cultural strengths, an important cultural identity, experiences of discrimination or oppression? 

f. Legal History 

Has the client ever been arrested? Give specifics. Facing legal charges? On parole or probation? If so, be sure to get the name of the probation officer. 

 Part II: Mental Status Exam: 

1. Appearance 

2. Attitude 

3. Motor Activity 

4. Affect 

5. Mood 

6. Speech 

7. Thought Process 

8. Thought Content 

9. Perception 

10. Orientation 

11. Cognitive Function 

12. Abstraction 

13. Judgment 

14. Insight 

 Part IV: Diagnosis 

The DSM-5 should be used and referenced as a part of this section. You should explain the way the client meets each criterion for the diagnosis. Remember that the client needs to meet every single criterion. You can also explain diagnoses you considered and why the client does not meet criterion. If the client does not meet criteria for any diagnosis, you should explain the diagnoses you considered and why the client does not qualify.

 Part V Case Conceptualization and Prognosis 

Here, explain your theory of the case and tie the information together. Why do you think the client developed the symptoms and diagnosis you offered? What is happening that has caused the client to seek treatment? How does the client’s environment impact the client? What is your current perspective about the situation? What is the client’s stage of change and motivation for change? 

Part VI Treatment Recommendations 

What treatment do you recommend? What skills does the client need to develop, in your professional opinion? Please offer at least one treatment modality and at least three client goals that are informed by your assessment. You should use research to inform your decision making. For example, if you recommend weekly therapy sessions and to use CBT to treat anxiety, you need to use research to back-up that recommendation.

Guidelines

· APA is not necessary for this paper. 

· Please write the title of the movie in the header of the paper 

· Reference the DSM in the diagnosis section. 

· Explain the way the client meets diagnostic criteria for the disorder they choose for diagnosis. 

· Use at least 2 academic references in the treatment planning section. 

· The recommendation treatment needs to be supported by the literature. For example, if the client is diagnosed with PTSD, the student should use research to describe the treatment recommended in the treatment plan (for example, EMDR might be recommended) 

· 6 to 8 pages of written text.

· The paper does not need to be double-spaced, but it should be written up like a treatment document….

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