Using cumulative knowledge from the course, students will outline the following considerations in their assessment; provide 3 e
Using cumulative knowledge from the course, students will outline the following considerations in their assessment; provide 3 examples as to why it will be important for you as the clinician to practice emotional and self awareness in working with this client, 2 theories that correspond with the presenting concerns that you would use as a basis of intervention considerations citing 2 references to support your rationale, 2 therapeutic interventions you would consider in working with this client citing 2 references to support your rational and 3 questions you had while completing your assessment.
Students will upload their case scenario, along with the complete biopsychosocial assessment, and 3 questions you had while completing your assessment. Students will then review 3 of their classmates scenarios, assessments and questions and will provide a sound clinical response with 3 references to support your response.
The following areas must be addressed in the assessment.
- Demographic Data and Presenting Problem (why this client is in your office)
Date, name, age, sex, race, source of income, marital status, living arrangements, etc.
- Family History
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.
- Education and Work History/Military
- Psychiatric and Medical History
Current medications and doses, are you taking as prescribed, history of suicidal/homicidal ideation, describe attempts, history of abuse, current stressors (deaths, divorce, financial, etc.
- Chemical Dependence History
First use, current use, last use, history of treatment, history of DT’s blackouts, seizures, family history of treatment, do you smoke, physical disabilities.
- General Appearance and Mental Status:
- Attention
- Memory
- Information
- Attitude
- Perceptual Disturbances
- Thought Content
- Speech
- Affect
- Willingness to participate
- Ability to participate
- Body Weight
- Groom/Hygiene
- Speech
- Mood
- Affective State
- Signs/Symptoms
- Thought Form
- Perception
- Judgment
- Insight
- Oriented to
- Clinical Impressions (theories with rationale) and Recommendations (interventions with rationale)
Case Scenarios (Note: The "subject" or client should be the child/adolescent in the case study)
Biopsychosocial Assessment Outline for SW660 (revised January 2022)
Please use the same headings to divide the content but do not use the letters in the details of the outline; rather, write the information in a narrative (sentence) format.
The following areas must be addressed in the assessment.
1. Demographic Data
Date: 12/3/2021
Name: J. Jacobs
Age: 27
Sex: Male
Race: Indian
Source of income: Business
Marital Status: Single
Living arrangements: Lives alone but has friends around the area he is in.
2. Presenting Problem
The patient was having different symptoms. He complained on him be easily irritated, they get to be more overwhelmed and nothing is making them happy around them and they tend to feel sad more and more. He had some impulsivity of most. He is a t a high risk of getting depressed.
2. Family History
E is the only child of a broken family. His parents divorced when he was still young and was raised by a single mum who was irresponsible and was much drunk. His extended family also separated when the marriage failed. All is life it has just been him and his mother who was at some point violent and always absent when it come. He was in a relationship with a girl who left and broke his life and through that he met many more ladies he slept with and left. He had many friends that have been loyal.
3. Education and Work History/Military
Jacobs is not working in any place that is because he was recently fired from his work place because he was reckless and irresponsible. He was educated and had gone through school to study sales and marketing though he is not interested in practicing it.
4. Psychiatric and Medical History
While in high school he was abusing marijuana and was taken to rehab center and a therapy session.
5. Substance Use History
He has a history of abuse of marijuana. He currently using cigarettes, marijuana and alcohol.
6. General Observations and Mental Status:
A. Appearance, grooming/hygiene, size/weight, is clothing appropriate to the weather/setting- he looked very careless and dirty in the clothing and the body state that he was in.
B. Ability to participate/Effort made/Motivation- he was inactive in most of the things and activities that he was partaking in
C. Orientation (who, what, where, day, date, time)-
D. Cooperation/Attitude- e had a negative attitude and he didn’t love everything around him
E. Attention, posture, Eye Contact, psychomotor agitation or retardation- he looked dehydrated in his eye
F. Speech (rate, tone, volume, content, fluidity, accent)- staggering, vulgar speech that was delivered slowly in a loud voice
G. Affect and its congruence with mood- just in a short time John with provoked with the tinniest things.
H. Mood (as they describe it and your assessment) – somber mood
I. Memory (does it appear intact, did you do memory test, obvious problems? Consider short and long-term)- he has a short term memory and forgets things easily.
J. Thought Process (logical, linear, tangential, circumstantial, etc) – circumstantial
K. Thought Content (bizarre, typical, appropriate to the setting and situation, etc)- typical
L. Perceptual Disturbances, hallucinations, loss of rational thinking, suicidal/homicidal- he has experienced a lot of hallucinations
M. Judgment- addicted and was experiencing the process addiction.
N. Insight- depression
7. Clinical Impressions (theories with rationale)
The patient looked more depressed and dependent on arrival. He was dehydrated and malnutritioned. He was underweight and looked sick.
8. Recommendations (interventions with rationale)
Rehabilitation center. Book therapy sessions that are relevant to the patient. Drugs that will help him on the developed conditions and reverse the psychological effects. Have all the plans to prevent illnesses and find the treatment plan in managing the pain. Try and reconnect him to his mother and give him a diet plan.
Three questions.
How do you create a safe space so that you can get all the information that will aid and help in patient’s diagnosis?
What are the considerations that should be put in place when prescribing treatment plan for the above patient?
What is the intervention that will help the patient to attend all their assigned therapy sessions?
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
