Practicum – Assessing Clients

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.
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).

I send a sample..

Rubric:

uality of Work Submitted:
The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking.–
Excellent 27 (27%) – 30 (30%)Good 24 (24%) – 26 (26%)Fair 21 (21%) – 23 (23%)Poor 0 (0%) – 20 (20%)

Quality of Work Submitted:
The purpose of the paper is clear.–
Excellent 5 (5%) – 5 (5%)Good 4 (4%) – 4 (4%)Fair 3.5 (3.5%) – 3.5 (3.5%)Poor 0 (0%) – 3 (3%)

Assimilation and Synthesis of Ideas:
The extent to which the work reflects the student’s ability to:

Understand and interpret the assignment’s key concepts.–
Excellent 9 (9%) – 10 (10%)Good 8 (8%) – 8 (8%)Fair 7 (7%) – 7 (7%)Poor 0 (0%) – 6 (6%)

Assimilation and Synthesis of Ideas:
The extent to which the work reflects the student’s ability to:

Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources.–
Excellent 18 (18%) – 20 (20%)Good 16 (16%) – 17 (17%)Fair 14 (14%) – 15 (15%)Poor 0 (0%) – 13 (13%)

Assimilation and Synthesis of Ideas:
The extent to which the work reflects the student’s ability to:

Synthesize (combines various components or different ideas into a new whole) material in course resources (i.e. video, required readings, textbook) and outside, credible resources by comparing different points of view and highlighting similarities, differences, and connections.–
Excellent 18 (18%) – 20 (20%)Good 16 (16%) – 17 (17%)Fair 14 (14%) – 15 (15%)Poor 0 (0%) – 13 (13%)

Written Expression and Formatting

Paragraph and Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused–neither long and rambling nor short and lacking substance.–
Excellent 5 (5%) – 5 (5%)Good 4 (4%) – 4 (4%)Fair 3.5 (3.5%) – 3.5 (3.5%)Poor 0 (0%) – 3 (3%)

Written Expression and Formatting

English writing standards: Correct grammar, mechanics, and proper punctuation–
Excellent 5 (5%) – 5 (5%)Good 4 (4%) – 4 (4%)Fair 3.5 (3.5%) – 3.5 (3.5%)Poor 0 (0%) – 3 (3%)

Written Expression and Formatting

The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.–
Excellent 5 (5%) – 5 (5%)Good 4 (4%) – 4 (4%)Fair 3.5 (3.5%) – 3.5 (3.5%)Poor 0 (0%) – 3 (3%)

Week 3

Assignment 2: Practicum – Assessing Clients

Name: Amina. H

DOB; 1/10/1987

Age: 32

Gender : Female

Race: Black or African American

Facility: REH Crisis Stabilization Program

City: Minneapolis State: MN

Presenting problem- Excessive alcohol use, Homelessness

History or present illness

Amina is a Somali immigrant that left the war-torn country. She is experiencing an increase in mental health symptoms and stress, especially anxiety and other trauma-related stress. Having difficulty with connecting to other people due to several trauma-related symptoms and Currently homeless. Amina is required by CPS to remain sober and enter treatment in order to maintain custody of her six kids.

Past psychiatric history Amina has indicated that When under the influence of alcohol, Amina has gotten into fights at times. She is currently not using alcohol, and is requesting to be administered UA’s or breathalyzers to verify that she is not using alcohol.

Amina has endorsed racing thoughts and rumination, paranoia/fear, dissociation, difficulty staying asleep, nightmares, negative cognitions of self, others, and the world; crying episodes, depressed mood, heightened startle response, shakiness, and irritability

Medical history

Client denies syncope, lightshades, fever, or numbness or tingling States that her generalized pain is 8/10. administered 400mg of Ibuprofen.

Substance use history

Amina reported that she has had more than 10 years history of over using alcohol, and she seeking to enter Substance use treatment for alcohol

Developmental history

No history available. Patient is an immigrant from Somalia

Family psychiatric history

No history available

History of abuse/trauma

Amina has endorsed persistent worrying that is difficult to control, experience of war, experience of childhood physical abuse,

Review of Systems:

General: Denies fever chills or malaise, Denies weakness or fatigue. Client is alert and oriented to person, place, and time as well as to situation. Client weighs 176 lbs. but client expresses her ideal weight to be 140lbs

Skin, Hair Nails: No problems reported

HEENT- denies a headache, dizziness, or syncope. Denies any hearing issues, denies tinnitus. Denies problems or changes in his vision; denies blurred vision; denies seeing spots.

Cardiovascular: BP 124/104 on left arm sitting and 156/108 on right arm sitting. HR regular and at 97 beats per minute. Denies chest pain and palpitations

Pulmonary: Oxygen saturation 98%. Denies asthma or any other pulmonary disorder. Denies shortness of breath; respirations 16.

Gastrointestinal: Bowel is regular

Genitourinary: Regular urinary pattern

Neurologic: Client informs that she was diagnosed with polio when she was 7. Denies numbness and tingling; or paresthesia

Musculoskeletal– Client informs that she was diagnosed with polio when she was 7. Patient states that she has generalized aches and pains.

Hematology: Denies easy bruising or history of anemia

Endocrine: Denies increase thirst or urination,

Mental Health: Mental status exam

Amina presented cooperative during the clinical interview. Her eye contact is poor. Speech is clear, coherent, but tangential at times. Speaks broken English. She makes no unusual motor movements and demonstrates no tic. Mood was dysphoric. Affect however is restricted. She denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. She is alert and oriented to person, place, and time. She reported that there were six children and she is estranged from them due to her excessive alcohol use. She reported depression and has a noticeable restrained affect, with an occasional smile. She denies visual or auditory hallucination, and her thought process is intact. The client’s awareness is age appropriate and associated with proper judgment and understanding. She denies current suicidal ideation. The diagnostic test of Patient Health Questionnaire-9 (PHQ-9) was administered to the client. The score was 16, which indicates severe depression.

Differential diagnosis

Depression, Post Traumatic Stress Disorder (PTSD), Alcohol Use Disorder

Case formulation

Drawing up from psychiatric viewpoint, the premise of Amina issues may have result from been a witness and experience of war, and extensive childhood physical abuse, and overall the family is not supportive, and lost custody of her children. Her presentation is congruent with reported content.

Treatment plan

Goal #1

Amina will be able to reduce and manage her anxiety

Objective

Amina will develop her coping skills, and build on her current coping approaches of breathing, prayer, and self-soothing techniques such as taking a walk.

Intervention

Staff will check in with Amina 2-3 times to assess her practice of coping skills, and to offer information regarding additional coping skills including progressive muscle relaxation, visualization, assertive communication of her feelings.

Goal #2

Amina will attend her therapy sessions

Objective

Amina will continue her sessions with the trauma-informed therapist, with an upcoming appointment next week.

Intervention

Staff will process current feeling about what to expect and how she is feeling about the appointment.

Goal #3

Amina will complete a substance use disorder (SUD) treatment.

Objective

Amina will complete rule 25 assessment to be able to gain admission into treatment center at Park Ave Women’s center.

Intervention

Staff will encourage Amina to attend her assessment session and develop a relapse prevention plan.