Biopsychosocial Assessment: Treatment Plan, Communication with Clients ESSAY

Biopsychosocial Assessment: Treatment Plan, Communication with Clients (Coursework Sample)
Mini Mental Status Exam or Other Assessment Instruments Administered: N/A
Treatment Plan
Identifying Information N/A

This section will describe pertinent information relative to the client.

*For the purposes of this case study, the identifying information will be the case study description.
Present Problem

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Identify the primary problem(s), the precipitating factors for the client to seek treatment, and whether or not this is a voluntary client (vs. being compelled by another person or outside agency). Briefly describe these factors in paragraph form.
Other Assessments

In addition to the biopsychosocial assessment you completed for this client, describe the process you will use to complete a clinical assessment for this client, including any other assessments that you feel are pertinent. Provide a rationale for each of your choices, including any concerns with the relevance and biases of potential assessment tools with multicultural populations. If you plan to refer your client to another mental health professional for all or parts of the assessment, identify who that will be and what you will ask that professional to assess.
Short Term Goals( N/A)

Using the Problem Identification and Goal Setting Template that you completed for this client, identify 2–3 short-term goals, that you have developed in conjunction with your client.
Long Term Goals (N/A)

Again, use the Problem Identification and Goal Setting Template for this client to identify long term goals that have been developed for this client. of the clinician.
Treatment Plan Interventions Annotated Bibliography (N/A)

Based on your diagnostic impression, develop an annotated bibliography of resources describing suggested interventions for the client. You should describe each source in your own words, not simply use the provided abstract. You will utilize a minimum of five current articles from peer-reviewed journals in the counseling or related professions from the Capella Library. Cite and reference the resources using APA 6th edition guidelines. You may utilize your textbook, but it does not count as one of your five scholarly resources. You are also encouraged to utilize more than five resources if they aid in developing a comprehensive treatment plan.
Communication with Other Professionals (N/A)

Identify other professionals that you anticipate will be involved in the care for this client. Explain how you will arrange for communication with them and what you are likely to communicate to each of them. Identify the kind of information you will need from each source.
Legal, Ethical and Other Considerations

Identify and discuss any ethical and legal ramifications relating to the treatment you are considering. Be sure to indicate whether the ramification is ethical or legal and cite the specific ethical standards or laws that will guide your decisions. Explain how you will address these.

Biopsychosocial Assessment
xxxx University

Client is a 37 year old male who has presented for counseling due to the recent issue of finding out that his wife was unfaithful. Reports he is having difficulty in several domains of his life and wants help figuring out what to do. Client has been working at the same job for the past 16 years. He is an engineer at a local firm. Client reports that he is satisfied with his job. Client has a bachelor’s degree in mechanical engineering. Client reports that he is financially secure and is not worried about financial issues at this time in his life. Client reports holding Christian faith. He states that he attends church with his wife at least 2 times per month and that is important to them to raise their daughter and son with these values. Client reports a daughter who is 8 and a son who is 6.
Client states that he has few friends and little time for extra-curricular activities. States that he does enjoy fishing, hunting, and gun collecting but that none of these activities seem very enticing over the past several weeks. Client does report having two very close friends that he has maintained since childhood. He states that these friendships have been helpful for him in the past several weeks after he discovered an email between his wife and a man from her work but both friends are telling him he should get out of the relationship because of what his wife did. Client reports that his drinking has increased over the past couple weeks and that he is utilizing alcohol as a way to cope with the current problem. He states that he is drinking 2 to 3 vodka and tonics nightly and that this amount is unusual but it is one of the ways that he is able to sleep and not have to think about what she did. Before finding out about this incident, client reports drinking one to two drinks a week. Client reports no prior problems with alcohol but he does report binge drinking with fraternity buddies while in college. Reports this stopped soon after he accepted a full-time engineering position. Client reports no current or past drug use. Does report trying marijuana while in college but stating he didn’t like it. Client is a non-smoker. Client reports no other general medical concerns.
Client and wife have owned their home for the past 10 years and are satisfied with their living conditions. Reports that his parents live nearby and consist of both his mother and father. States he has not told his parents yet because he knows they will be very mad at his wife. Also reports that he has a sister who he is close to but she lives in Georgia. States he did tell his sister because she left her husband after he cheated on her. States that his parents are still married and have always appeared to be happy. States that he does not have significant issues with his immediate family from when he was a child.
Client states that two weeks ago while looking through some emails he found an email between ‘some guy’ and his wife. States that he immediately knew that the emails were inappropriate because they discussed intimate issues between his wife and ‘that guy’. States that he confronted his wife that evening and his wife denied any such an issue until client produced the emails. States that since that time him and his wife have been arguing non-stop. Reports he cannot believe whether or not the information she is telling him is true and is worried that the relationship between his wife and ‘that guy’ is significant. States that he recognizes that his relationship with his wife has been distant over the past few year but sites issues of work stress as the cause. States over the past two weeks that he is having headaches, that he feels sick to his stomach, that he is crying, that he cannot concentrate, that he is having nightmares and visions of his wife having sex with ‘that guy’. Reports t…

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