1. Case Study: see below case and instructions
use the components of a written biopsychosocal assessment
use the mental status checklist
2. Assessment : HX, Diagnosis, and current problem
3. Treatment Plan -Goals (What do you want your client to achieve. What changes do you want to see.
How will measure
4. Implementation of Therapy Model- measurement how do you know its working
6 Identifying information example age sex ethnic group
7 presenting problem
8 current situation
9 previous mental health problem
10 background information
12 recommendations/intervention plan
Use the DSM-IV
Casey, a 24-year-old Caucasian woman, is seeking counseling for anxiety and depression that she attributes to problems in her current relationship. She and her partner have been having an increasing number of arguments recently, typically about Casey’s behavior when they go out and about Casey drinking too much.
In response to questions about her use of substances, Casey describes herself as a “social drinker.” Her typical pattern is to consume 3-6 drinks during each of 2-3 drinking occasions per week. She began drinking regularly (1-2 times per week) and heavily (to intoxication) at the age of 13, usually in the company of an older cousin or school friends. She continued this pattern through high school but cut back during her first two years of college due to lack of money to buy alcohol and more difficult access.
During her junior and senior years, Casey “came out” as a lesbian to her parents and family. She also resumed drinking heavily. After graduation from college, Casey and her partner of 3 years (Angie, age 24) moved into an apartment together, as both began working full-time. Casey and Angie are “out” at work and with both families of origin.
Casey reports that they both decreased their drinking at this point, due to concerns about their finances and interest in starting their new careers. Both partners gradually increased the frequency and quantity of their drinking, as they became involved with a social group of older (late 30’s) lesbians and began routinely going to a gay bar.