Mini Mental Status Exam or Other Assessment Instruments Administered: N/A
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.
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.
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.