FIVE REFERENCE NOT MORE THAN 5 YEARS
NOTE: Patient is 59 years old African American male who was admitted to the long term due declining in health. Patient is alert and verbally responsive. He was admitted with diagnosis of Mood disorder, depression and Bipolar disorder. Patient on the following medications: Risperdone 0.5mg 1 tab PO at bedtime. Depakote 250mg 3tabs PO at bedtime. Patient reported that he is feeling great today. Patient was seen by the psychiatrist in February and no medication reduction was recommended. Patient was encourage to not refused his medication and report any unusual feelings.
- Assess clients presenting for psychotherapy
- Develop genograms for clients presenting for psychotherapy
To prepare:
- Select a client whom you have observed or counseled at your practicum site.
- Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.
The Assignment
Part 1: Comprehensive Client Family Assessment
With this client in mind, address the following in a Comprehensive ClientAssessment (without violating HIPAA regulations):
- Demographic information
- Presenting problem
- History or present illness
- Past psychiatric history
- Medical history
- Substance use history
- Developmental history
- Family psychiatric history
- Psychosocial history
- History of abuse/trauma
- Review of systems
- Physical assessment
- Mental status exam
- Differential diagnosis
- Case formulation
- Treatment plan
Part 2: Family Genogram
Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).