Biopsychosocial Assessment: Part 2
Biopsychosocial Assessment: Part 2
Refer back to the movie you selected and watched or the case study you read during Topic 1. Continue working on the biopsychosocial assessment submitted in Topic 2 and complete Part 2 of the biopsychosocial assessment. Make any suggested changes from your instructor.
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While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
You are required to submit this assignment to Turnitin. Refer to the directions in the Student Success Center.
This assignment meets the following CACREP Standards:
2.F.5.h. Developmentally relevant counseling treatment or intervention plans.
5.C.3.a. Intake interview, mental status evaluation, biopsychosocial history, mental health history, and psychological assessment for treatment planning and caseload management.
This assignment meets the following NASAC Standards:
25) Gather data systematically from the client and other available collateral sources, using screening instruments and other methods that are sensitive to age, culture and gender. At a minimum, data should include: current and historic substance use; health, mental health, and substance-related treatment history; mental status; and current social, environmental, and/or economic constraints on the client’s ability to follow-through successfully with an action plan.
28) Determine the client’s readiness for treatment/change and the needs of others involved in the current situation.
29) Review the treatment options relevant to the client’s needs, characteristics, and goals.
31) Construct with the client and others, as appropriate, an initial action plan based on needs, preferences, and available resources.
32) Based on an initial action plan, take specific steps to initiate an admission or referral, and ensure follow-through.
33) Select and use comprehensive assessment instruments that are sensitive to age, gender and culture, and which address: (a) History of alcohol and other drug use (b) Health, mental health, and substance-related treatment history (c) History of sexual abuse or other physical, emotional, and verbal abuse, and/or other significant trauma (d) Family issues (e) Work history and career issues (f) Psychological, emotional, and world-view concerns (g) Physical and mental health status (h) Acculturation, assimilation, and cultural identification(s) (i) Education and basic life skills (j) Socio-economic characteristics, lifestyle, and current legal status (k) Use of community resources (l) Behavioral indicators of problems in the domains listed above.
34) Analyze and interpret the data to determine treatment recommendations.
36) Document assessment findings and treatment recommendations.
37) Obtain and interpret all relevant assessment information.
111) Prepare accurate and concise screening, intake, and assessment reports.
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PCN-610.R.Option2CaseStudy4.docxPCN-610 Option 2: Case Study
David is a 49-year-old married man with two adult children. He has been married for 21 years. He has been employed as a metallurgical engineer in a local steel mill for 20 years. David noted he use to enjoyment going to work, but now, he states some days he would rather just stay home. David married his high school sweetheart. He describes their relationship as “typical.” They eat meals and attend family gatherings together but do little else as a couple. David use to spend his spare time reading, playing golf, and watching TV. For the last 6 months, David has felt blue and his appetite has decreased. He stated he doesn’t have any desire to do any of things he use to enjoy and would rather spend time alone in his bedroom. David complained of irritability and low energy. Within the last 2 months, David noted he has experienced more physical pain in his back and neck area. Because he has not been sleeping well, Robert drinks more at night. He stated that when he was younger, he use to drink more frequently but now he only drinks two or three beers per night. Sometimes, he feels like life is hardly worth living. Robert has tried to “snap himself” out of this sour mood, but nothing seems to work. David oldest son stated he is concerned his father may need to go see a doctor, because his father appears to be acting usual. David stated that his sister used to have similar problems. He is resistant to going to see a doctor and believes his mood will eventually improve.
David’s sister Lisa has struggled with depression for over 10 years. She is currently seeing a psychiatrist and a counselor. In the past, Lisa reported an increase in emotional and physical fatigue, low mood, increased weight gain, and disrupted sleep. Lisa has a negative outlook and states that when things are looking up, something always goes terribly wrong.
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PCN-610.R.T2-T3BiopsychosocialTemplate4.doc
Psychosocial Assessment ____ Part 1 (Topic 2)Template ____ Part 2 (Topic 3)
Name: ______________________________ Date: _________________ DOB: ________________
Age: ________________________________ Start Time: ____________ End Time: ___________
Identifying Information:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Presenting Problem:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Life Stressors:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Substance Use/Abuse: FORMCHECKBOX Yes FORMCHECKBOX No
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Addictions (i.e., gambling, pornography, video gaming)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medical/Mental Health Hx/Hospitalizations:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Abuse/Trauma:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Social Relationships:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Family Information:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Spiritual:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Suicidal:
________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Homicidal:
________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Assessment:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Initial Diagnosis (DSM):
________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Initial Treatment Goals:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Plan:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name: _____________________________________________ Date: __________________
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