Antoine Ford, 25-year-old, African American Male, Bipolar Disorder
***Case File Client: Antoine Ford, 25-year-old, African American Male, Bipolar Disorder***
SEE ATTACHMENTS:
1. Instructions and Rubric
2. Initial Intake
3. Assessment #1 (Colombia_Suicide_Risk_Assessment)
4. Assessment #2 (Becks Depression Inventory)
5. Treatment Plan Parts/Examples
4. SOAP Note & Example for reference (3 should be completed)
Instructions for Case File
Clinical Mental Health and School Counseling
(a) conduct an initial interview with a person who has a mental illness and is at least 18 years of age (give a summary of information received from the interview)
(b) complete at least two self-administered assessment instruments (i.e., you will not have the person you interviewed complete them, you will complete them yourself as if you are your client)
(c) score and interpret the assessment results
(d) prepare a written treatment plan with SMART treatment goals, objectives, and interventions
(e) identify community resources appropriate for supporting the client/consumer. Case files should also include several case notes (at least three and SOAP notes are fine). All case notes must be typed and proofread for spelling and grammar errors.
***SOAP NOTES: Imagining how the 3 sessions would go with the client!
You may choose whatever format you prefer: all narrative, narrative with tables, or any form from our textbook or other sources. Be sure to use APA style and use Spell Check/Grammar Check before submission to catch typos and grammar errors.
Grading Rubric for Case Study
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Exceeds Expectations |
Meets Expectations |
Below Expectations |
Comments |
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Treatment goals |
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Objectives |
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Objective Measurements |
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Resources Required |
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Assessments Required |
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Missing Information |
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Specific Concerns |
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Case notes |
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Community Resources |
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(Rehab-Vocational goals) |
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(Rehab-assistive technology) |
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Grammar/APA style |
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Use of Spell Check/Grammar Check – |
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Initial Assessment—Adult
Client’s name:
Date:
Starting time:
Ending time:
Duration:
PART A. BIOPSYCHOSOCIAL ASSESSMENT
1. Presenting Problem
2. Signs and Symptoms . . . Resulting in Impairment(s)
(Include current examples for treatment planning, e.g., social, occupational, affective, cognitive, physical)
3. History of Presenting Problem
Events, precipitating factors, or incidents leading to need for services:
Frequency/duration/severity/cycling of symptoms:
Was there a clear time when Sx worsened? Family mental health history:
4. Current Family and Significant Relationships (See Personal History Form) Strengths/support: Stressors/problems: Recent changes: Changes desired: Comment on family circumstances:
5. Childhood/Adolescent History (See Personal History Form)
(Developmental milestones, past behavioral concerns, environment, abuse, school, social, mental health)
6. Social Relationships (See Personal History Form) Strengths/support: Stressors/problems: Recent changes: Changes desired:
7. Cultural/Ethnic (See Personal History Form)
Strengths/support: Stressors/problems: Beliefs/practices to incorporate into therapy:
8. Spiritual/Religious (See Personal History Form) Strengths/support: Stressors/problems: Beliefs/practices to incorporate into therapy: Recent changes: Changes desired:
9. Legal (See Personal History Form)
Status/impact/stressors:
10. Education (See Personal History Form)
Strengths: Weaknessess:
11. Employment/Vocational (See Personal History Form) Strengths/support: Stressors/problems:
12. Military (See Personal History Form)
Current impact:
13. Leisure/Recreational (See Personal History Form) Strengths/support: Recent changes: Changes desired:
14. Physical Health (See Personal History Form)
Physical factors affecting mental condition:
15. Chemical Use History (See Personal History Form)
Patient’s perception of problem:
16. Counseling/Prior Treatment History (See Personal History Form)
Benefits of previous treatment: Setbacks of previous treatment:
PART B. DIAGNOSTIC INTERVIEW
Mood (Rule in and rule out signs and symptoms: validate with DSM V, as appropriate)
Predominant mood during interview:
Current Concerns (give examples of impairments (i), severity (s), frequency (f), duration (d))
_________________________________________________________________________________
_________________________________________________________________________________
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Mental Status
(Check appropriate level of impairment: N/A or OK signifies no known impairment.
Comment on significant areas of impairment.)
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Appearance |
N/A or OK |
Slight |
Moderate |
Severe |
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Unkempt, disheveled |
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( ) |
( ) |
( ) |
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Clothing, dirty, atypical |
( ) |
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Odd phys. characteristics |
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Body odor |
( ) |
( ) |
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( ) |
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Appears unhealthy |
( ) |
( ) |
( ) |
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Posture |
N/A or OK |
Slight |
Moderate |
Severe |
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Slumped |
( ) |
( ) |
( ) |
( ) |
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Rigid, tense |
( ) |
( ) |
( ) |
( ) |
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Body Movements |
N/A or OK |
Slight |
Moderate |
Severe |
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Accelerated, quick |
( ) |
( ) |
( ) |
( ) |
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Decreased, slowed |
( ) |
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Restlessness, fidgety |
( ) |
( ) |
( ) |
( ) |
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Atypical, unusual |
( ) |
( ) |
( ) |
( ) |
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Speech |
N/A or OK |
Slight |
Moderate |
Severe |
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Rapid |
( ) |
( ) |
( ) |
( ) |
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Slow |
( ) |
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Loud |
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Soft |
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Mute |
( ) |
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( ) |
( ) |
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Atypical (e.g., slurring) |
( ) |
( ) |
( ) |
( ) |
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Attitude |
N/A or OK |
Slight |
Moderate |
Severe |
|
Domineering, controlling |
( ) |
( ) |
( ) |
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