Eliza D. paper

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Humanities

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This assignment contains four parts, as identified and described below. Please include four subheadings in your paper that clearly identifies each part. Include the following:

Part 1: Intake

  1. Read and review the Eliza intake document.
  2. Assess how you would use the Level 01 Cross-Cutting Measure (CCM-1), in addition to what specific questions would need to be answered by the end of the biopsychosocial assessment.

Part 2: Biopsychosocial Assessment

  1. Review the completed biopsychosocial assessment for Eliza.
  2. Provide an assessment related to client symptomology along with a DSM and ICD diagnosis based on client assessment.
  3. Provide the initial treatment goals and plan.

Part 3: Treatment Planning

  1. Determine what Level 02 Cross-Cutting Measure (CCM-2) you would utilize in future sessions based on the information provided.
  2. Identify one additional assessment outside of those provided by the APA that would measure what the future counselor is attempting to assess based on treatment goals/plan.
  3. Describe how you would convey the assessment findings to the client and family.
  4. Include how you would prioritize the needs and formulate agreed upon outcomes, measures, and strategies.

Part 4: Referral

  1. Identify any possible referrals you might make and how you might address them with your client.
  2. How would you know who to make referrals to and how would you follow up with the referral after you make it?

Be sure to include three to five scholarly resources in your paper.

Prepare this assignment according to the APA Style Guide.

Unformatted Attachment Preview

Eliza D City University 18 Dorm with friends I have to be here X X Joan Burt Elementary Secretary Okay Truck Driver Good none Eliza D Psychosocial Example Name: Eliza Doolittle ******** Date: ********* Age: 18 2:00p Start Time: 1:15p DOB: End Time: Identifying Information: The client is a Caucasian female with average height and slender build. The client stated that she is currently a freshman in college, majoring in engineering. The client also stated that her family resides in a small town approximately two hours away. Presenting Problem: At the onset of the session, the client stated that she had come to counseling as a result of being caught in a campus dorm with alcohol (it is an alcohol-free campus). Concerning the incident, the client stated “the RAs were called because my friends were being too loud in my dorm. When they arrived, they saw us with alcohol, and we got in trouble.” The client stated that her friends in the dorm were intoxicated but she was not, adding, “I was just buzzed” and adding that she was drinking “because they were” and “it’s just something to do.” Life Stressors: The client identified school as a life stressor, adding “things came easy to me in high school, I just figured it would be the same in college”. The client went on to state that, in addition to the difficulty in increased study requirements, she had struggles in making friends, stating, “a lot of my friends from high school have either gone to college somewhere else or are doing other things,” although the client denied feeling lonely. Substance Use/Abuse: Yes No The client denied having a drug or alcohol problem, adding that she tried marijuana once in high school but “I didn’t like how it made me feel” and had not taken it since. The client stated that she was introduced to alcohol in HS when “friends asked me to drink it with them.” The client stated that “I sometimes drink on the weekends with friends,” denying drinking in excess or ever suffering symptoms of being hungover. Addictions (i.e., Gambling, pornography, video gaming) The client stated that she occasionally plays a Massive Multiplayer Online game. When asked how often the client played, the client stated “one or two times a week” for approximately “three to five hours” at a time. The client denied gambling or pornography issues. Medical/Mental Health Hx/Hospitalizations: Any past mental health history or hospitalizations denied. Abuse/Trauma: The client denied any current or past abuse, although stating in passing that she did experience some level of teasing in HS, although the client denied discussing specifics. Social Relationships: The client stated that she had quality relationships, but added that she felt as though she was, at times, being taken advantage of. When asked for details, the client stated that her friends oftentimes pressure her to complete their homework, as well as often push her to “party in my dorm.” When asked if the client had ever talked with her friends about said issues, the client stated that she had not, adding, “it’s not that big of a deal.” Family Information: The client stated that she was the only child in her family, describing her mother as “kind of controlling” and her father as “a good guy.” The client went on to state that her mother required her to call approximately once a week “or else she gets worried,” adding that during HS her mother “was always asking where I was going or what I was doing.” The client stated that her parents seemed to have a strained relationship at times, stating, “when I call, I talk to my mom first, and then she hands the phone off to my dad, and he goes into another room to talk with me.” The client also stated that the two frequently complain to the client about the current status of their marriage. In the conversation, the client also acknowledged sometimes feeling as though she were “the middle man” when living at home. Spiritual: The client identified as being an agnostic. The client also stated that her parents are Irish Catholic, even though “they mostly only go to church on Christmas and Easter.” Suicidal: Denied. Homicidal: Denied. Eliza D 18 X
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Running Head: BENCHMARK INITIAL TREATMENT: ELIZA

BENCHMARK Initial Treatment: Eliza
NAME OF STUDENT
INSTITUTION
PROFESSOR’S NAME
DATE

1

BENCHMARK INITIAL TREATMENT: ELIZA

2

BENCHMARK Initial Treatment: Eliza
Introduction
The Psychosocial Assessment is an important document, which sets up the foundation for
the future work. Through observations and clinical interview, the counselor is able to develop a
descriptive assessment to understand the client’s experiences and assist the diagnostic process. A
psychological assessment involves evaluation of patients mental health as well as social wellbeing. Being in a state of mental health entails being able to overcome the stress of life, work and
being able to perform thus productive in the community. Mental illness is manipulated by some
behaviors which shows a person is in trouble, stressed. The illness may be contributed by a
number of factors including work activities, life encounters and state of the community they live.
Psychological assessment assesses personal perception and one's ability to perform in the
community. In the psychological assessment, the patient is asked some questions to ascertain a
number of domains or issues (PsychGuides, 2016). This helps to understand the patients well in
order to provide the best suitable healthcare service. Psychological assessment is very import
activity as far as nursing care of a patient is involved.
Part 1: Intake
The basic segments of a psychosocial assessment include: Identifying the patient, the
main complainant, the historical backdrop of the illness presented, mental wellness history,
medicinal or surgical history, medical prescription notes, alcohol use, drug use, violence
behavior assessment, family history, social record, job or occupation information, education
background, legal knowledge, development history, spiritual assessment, cultural information,
financial information, coping ability, interests and the mental status examination. The initial

BENCHMARK INITIAL TREATMENT: ELIZA

3

phase of any assessment is to identify the patient. The identification of a patient incorporates the
patient's name, sexual orientation, birth date or age, marital status, race or ethnicity, and
language was spoken (Grohol, 2015, June 17).
The client, Eliza, is an 18 years old, Caucasian female student at City University. At the
first session, the client was provided with an intake document to complete. The client provided
limited information. From the information she did provide, she revealed that she is experiencing
anxiety and or stress and has low self-esteem. She disclosed that she has an okay relationship
with her mother Joan who is an elementary school teacher and that she has a good relationship
with her father Burt who is a truck driver. The client is not in treatment voluntarily. In order to
complete the psychosocial assessment, this counselor requested that the client complete the
Level-01Cross-Cutting Measure (CCM-1). The CCM-1 will be used as an initial screening tool
to later assist this counselor in identifying symptoms in (a) specific diagnosis(s). The completed
CCM-1 showed that the client is experiencing mild anxiety and should complete, DSM-5 Level 2
Cross-Cutting Symptom Measure-LEVEL 2-ANXIETY-Adult (PROMIS Emotional DistressAnxiety-Short Form) (American Psychiatric Association, 2016). To assist in completing the
assessment this counselor would request that both parents complete the Personality Inventory for
DSM-5-Informant Form (PID-5_IRF)-Adult (American Psychiatric Association & American
Psychiatric Association, 2013). Due to the client’s reluctance providing information, and not
attending treatment voluntarily, this counselor believes the information provided would be
beneficial in creating a clearer understanding of the client and her presenting issues.
At the completion of this psychosocial, the client’s presenting problem will be
determined, second, the counselor and the client will decide what the achievable goals will be,

BENCHMARK INITIAL TREATMENT: ELIZA

4

next, the treatment methods and intervention will be discussed and selected, and finally, how the
client’s changes and success will be measured will be determined, whether by self-reporting or
counselor evaluation.
Part 2: Biopsychosocial Assessment
Eliza is an 18-year-old, single, Caucasian female, referred to treatment by her college,
City University, as the result of being caught drinking alcohol with her friends in the dorm by the
RA. Eliza states’ she was just “buzzed” and did it because her friends believed “it was no big
deal.”
Eliza is of average height and slim build. She was...


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