Assignment 2: Practicum – Assessing Clients

Assignment 2: Practicum – Assessing Clients
Learning Objectives
Students will:
• 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 Assignment 2: Practicum – Assessing Clients.
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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).
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.

WEEK_3_Patient_Name (2)

Hernandez_family_genogram_[Video_file]._Baltimore__MD_Author.

Hernandez_family_genogram_[Video_file]._Baltimore__MD_Author._transcrpt

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