Complete an assessment and treatment plan of aadult you know personally or through work. This assignment offers the opportunity to practice an assessment interview and to complete the full process through treatment plan. You will use the materials provided for format. We will discuss how to adjust from DSM-IV-TR to DSM-V diagnosis.
More instrustions for assignment • Add impulse control and judgment under mental status, example within normal limits, do they have good judgment?
• Add after dx, criteria and discussion: this is where we talk about the case, because the person is depressed but has a good support system the treatment will be this..because they are really isolated we will do this.. or this is the dx we don’t have enough information yet to get a plan we are going to do it by getting testing, having client go to psychiatrist, see if client is willing to do family therapy. Im suggesting CBT because with depression there is so much around self talk.
• Add treatment after discussion.
Assessment reports may be organized as follows:
2. Date of birth:
3. Primary language:
4. Referred by:
5. Intake date:
6. Evaluated by:
7. Description of client:
Write what you observe about the client, such as age, sex, appearance, behaviors, and impressions.
8. Presented problem:
Describe the problem as the client presented it.
9. History of the problem:
Describe the course of the problem and the client’s symptoms.
10. Mental Status:
Describe the client’s cognitions, affect, behaviors, and physiological functioning.
For example: The client’s range of affect is somewhat limited and flat.
For example: The client appears to be depressed.
• Physiological functioning
• Suicidal and homicidal assessment
11. Social history:
Describe the client’s present living situation and his or her family, school, health, and social history.
12. School history:
Note. Fill this section out for minors only.
Describe assets that facilitate progress and change, such as motivation, intelligence, self-discipline, and willingness to utilize resources.