Janice is a 62-year-old African American Female who lives alone. She has one child and 3 grandchildren, her mother passed away about ten years ago. etc
Jan suffers from Bi-Polar disorder (F31). Her presenting Anxiety
Depression
Mood changes
Trouble falling or staying asleep
Mood swings
Social withdrawal
she came to treatment because of depression and loneliness
Intake Summary.
Demographic description.
Presenting problems.
Background Information.
History relevant to treatment.
Family background.
Work and education history.
Medical history.
Previous mental health treatment
Clinical Impressions.
DSM-5-TR diagnosis.
You will need to do differential diagnosis in your presentation.
How did you come up with the diagnosis that you did and how did you rule out other diagnoses?
Remember to make it evidence-based.
Description of Client Functioning.
Cognitive.
Affective.
Behavioral.
Physical appearance.
Strengths.
Client-therapist match.
Get creative: consider using a poem, song, artwork, video, dance, metaphor, et cetera to describe the match.
Include cultural dynamics related to gender, race, sexual orientation, age, religion, et cetera.
Include countertransference issues.
Treatment.
Conceptualization of client’s difficulties.
Integrate theory.
Client’s progress to date.
For example, what number of sessions, mutually agreed-on treatment goals, and interventions were effective and ineffective.
Include case notes.
Medication use, experience, research, and counselor role.
Identify the following:
The medication(s) and dosage.
How long the client has been taking the medication.
The client’s thoughts about taking the medication.
Your client’s symptoms before they started taking the medication.
The changes the client noticed since beginning the medication
This would include both a lessening of symptoms and any side effects.
Any difficulty the client had taking the medication as prescribed.
The mechanism of action for the medication.
The class or type of medication.
How the medication is specific to the identified mental disorder.
The common and more severe side effects, indications, and contraindications, and some of the consequences of abruptly stopping the medication.
How these side effects, indications, and contraindications inform treatment planning.
Ethical and legal issues related to discussions of medication with clients.
Outline how you would address medication with this client.
If your client does not take medication, explore what medication may be helpful.
Unanswered questions.
Rank with most salient first.
What do you need from the group?
Competencies Measured
By successfully completing this assignment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
Competency 1: Apply mental health counseling theories and research to contemporary clinical practice.
Identifies goals and strategies for the counseling process that are specific, related to client’s presenting problem, and largely congruent with chosen theoretical perspective.
Competency 2: Deliver culturally and ethnically sensitive counseling/therapy services to clients.
Clearly articulates useful strengths; identifies several key resources and limitations related to diversity, oppression, and marginalization; and explores differential diagnosis.
Competency 3: Evaluate the impact of psychopharmacological medications on clients with mental and emotional disorders.
Research psychopharmacological medications, side effects, and contraindications to inform treatment planning.
Describe the classifications and indications specific to the identified mental disorder.
Detail the side effects and contraindications of psychopharmacological medications specific to identified mental disorders.
Competency 4: Apply the American Counseling Association Code of Ethics to professional behavior and practice.
Identifies client age, ethnicity, occupation, gender, et cetera in a complete introduction; provides understanding of client presenting problem in the description; includes useful summary of recent and past events and traumas with time frames.
Competency 7: Think and write critically in the mental health counseling discipline and professional practice.
Communicate in a manner that is consistent with expectations of mental health counseling professionals.
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