Assignment 2: Practicum – Assessing Clients

Learning Objectives

Students will:

Assess clients presenting for psychotherapy
Develop genograms for clients presenting for psychotherapy Assignment 2: Practicum – Assessing Clients
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.
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The Assignment

Part 1: Comprehensive Client Family Assessment

With this client in mind, address the following in a Comprehensive Client Assessment (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). Assignment 2: Practicum – Assessing Clients

Patient Name: A,R

Sex: F

Date of birth: 10-25-02

Age: 16

Legal Status:

Preferred Language: English

Contact: 677-651-0267

Vital signs completed: 1:38

B/P: 126/73

P: 66

R: 17

Temp: 95.1

Pulse Ox: 99%

Time; 2:40

Patients Self-reported height: 5’5”

Weight: 125

PT is a 16 y.o. female- pmhx of depression, suicide. Con 10 mg celexa () presenting for aggressive behavior + 1013 hold . Pt has agitation + behavioral problems. Pt reportedly threatened suicide 2 weeks ago if her parents didn’t let her go live at her grandmothers home (per hospital assessment) mother is concerned that A,R is at risk of harming herself. Mother reports that AR has unusual behavior + episodes where she says things that did not happen + where she is out of touch (doesn’t recall) with what she does. Assignment 2: Practicum – Assessing Clients