Client Assessment And Treatment Plan Essay
Treatment Plan
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Write My Essay For MeProblem/Symptoms:
The presenting problem is the focus of treatment and the mental health diagnosis should be based upon this. Each client presents with unique nuances as to how a problem behaviorally reveals itself. It is important to identify and list the symptoms of the problem in a way that would justify the DSM diagnosis.
Example:
Patient reported she has been feeling depressed for the past three weeks. She reported feeling a constant heavy sadness, having low energy, having little to no appetite, and sleeping excessively. She reported she thought about suicide several times a week, but denied a having a plan.
Read more: How to write a diagnostic essay about yourself.
Goals
The goal, objective, and intervention must be based on the problem/diagnosis and be specific, quantifiable and observable and applicable to the client’s needs and abilities. The client should be able to see how working towards the goal will help to resolve the stated problem. In measuring the goal and intervention, it is helpful to include numbers, but avoid using percentages(%). Example: Patient will reduce suicidal thoughts to one or less time per month.
Pt will increase energy level to participate in enjoyable activities at least four days per week.
Pt will reduce amount of time spent sleeping to 8 hours per day at least five days a week for one month.
Objectives
Short term action steps that the client will do to accomplish their goals. These are simple, straightforward, measurable, achievable, realistic and timed framed. As with goals, they are also specific, quantifiable, and observable. Example: Patient will attend 8 individual counseling sessions once per week for 60 minutes.
Patient will take medication as prescribed by psychiatrist, keeping follow up medication evaluation appointments and reporting side effects as they occur. Patient will identify three enjoyable activities that help to reduce her sadness. XX will log the use of these activities in her journal.
In therapy sessions, patient will identify 6 recurrent negative thoughts that precede suicidal thoughts and replace them with more positive, adaptive thoughts
Interventions/Actions
Interventions are the actions of the clinician designed to help the client complete their objectives. They should be consistent with the goals and must include duration. All services provided to the patient should be included in this section. To be precise for the coders, you should also include CPT codes to describe. Example: SW will provide group therapy once per week for 90 minutes
SW will provide individual therapy for 60 minutes 1 x per week and utilize cognitive behavioral techniques to assist patient in stabilizing symptoms
SW will link patient with psychiatric resources for medication as needed for the next 6 months.
Client Assessment And Treatment Plan Essay
Substance Abuse Clinical Assessment & Treatment Plan
Name of Client: David J
General Information:
18yo male, currently seeking therapy @ community mental health center following a traumatic accident that ended any possibility for a football career
Medical / Physical Health Status:
family Dr. stated David possibly has depression as a result of the accident; still recovering from injury
Employment/Work History and Financial problems and Support Status: HS drop out; parent’s divorces, lives with mother, received support from siblings up to 2 months after accident
Drug/Alcohol Use and Treatment History:
Pain meds for injury; takes more than prescribed; tested positive THC meth & opioids; assuming this was the clients first visit to the therapist
Family History of Alcohol/Drug Use (2 generations):
none
Legal Problems / Legal Status:
Illegal drug use
Family History:
Parent’s divorced; Father is African American, Mother is Hispanic, no indication of family mental health issues or substance abuse
Family / Social and Interpersonal Relations:
Mother’s favorite child. Seems to have a hard time communicating with father, father is loud and angry, client is more open when father is not around, siblings were supportive following accident, however for the last 5 weeks they have been unsupportive. Only child living a home. He has a friend that comes over 2 -3 times per week.
Use of Recreational Time:
He used to enjoy seeing seeing school friends and playing video games, but now reports having no energy for much else. Complains of lacking energy to see people.
Psychiatric/Mental Health Status and Intra-personal View:
He reports “I might as well be dead, I can’t do anything now and never will” Self destructive behavior, eluding to loss of hope/giving up
Spirituality/Role of Religion:
unknown
Diagnostic Impression
AXIS I: Substance abuse related disorders. Mood disorder. Adjustment disorder. Possible Eating disorder
Description: pain med abuse and testing positive via urinalysis for THC, opioids, & meth. Mood swings – one moment he is excited and talkative & in a few hours or next day he will complain of not having any energy or interests. Adjustment – he felt that the accident was the end of any opportunity for a professional career, feeling hopeless, lack of enthusiasm for getting healthy. (Possible weight loss)
AXIS II: N/A
Description: N/A
AXIS III: Leg injury-compound fracture left leg above knee 10 months ago *Referred by primary care doctor
AXIS IV: Primary support group, educational problems. Problems related to social environment, other psychosocial and environmental problems
AXIS V: GAF: 47
Crisis management and intervention strategies:
drug use – address it, talk about it; suggest rehabilitation for drug use suicidal ideation- address issue with client
Treatment Plan:
A. Description of theoretical models used:
1. Short term goals:
i. Relief of symptoms of depression
ii. Restore relationships with previous friends
iii. Find at least one new activates that evoke positive feelings iv. Develop no self harm contract
v. David will report no suicidal ideation for 4 consecutive weeks vi. Learn coping skills to work on adjust and adapt to injury vii. Learn to identify maladaptive, negative thoughts and how to replce them with more positive adaptive thoughts which will be measured by demonstrating these skills during therapy sessions and by homework assignments for 4 consecutive weeks
2. Long term goals:
i. Explore education options
ii. Explore consistent individual therapy
iii. Substance abuse Recovery, Group therapy
iv. Improve sense of self and confidence
v. Stable support system
vi. Reduce symptons of depression
B. Model of individual therapy: (motivational interviewing, group therapy, fam therapy, etc) 1. Individual therapy twice a week for 4 weeks the once a week for 6 weeks until symptoms have approved pending other requirements and or limitations (insurance, treatments facility requirements, etc.) *Counselor and client will consistently determine the future course of the sessions. 2. Person Centered/Humanistic approach (he opened up with female therapists easily)
C. Adjunctive referrals:
1. Therapist will refer client to 12 step program (Narcotics anonymous, crystal meth anonymous, marijuana anonymous) and/or detox facility
D. Specific interventions for specific presenting issues:
1. Medication management-Reevaluate prescription medications with medical doctor 2. Individual therapy-explore, process,, & resolve depressive emotions and coping skills. 3. Family therapy-explore & help family to understand dynamics, negative patterns & problems in the family structure. Encourage family to learn & use communication and conflict resolution skills. 4. Physical therapy as a pain reduction to reduce pain meds 5. No self-harm contract
5. Increase parent’s and sibling’s ability to support & encourage
