planning when working with clients.
Follow the instructions provided in the “Treatment Plan Guidelines” to develop a treatment plan for one of the identified clients. You may use the “Treatment Plan Template” to complete the assignment. However, please be advised that the format of a treatment plan may vary depending on where you work.
Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment
Attachment
Treatment Plan Template
Allison W., 59-year-old Caucasian single female
Presenting problem:
Mental status exam:
Risk assessment:
DSM
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Short term goals:
Long term goals:
Possible treatment methods:
Medication:
Sonia B., 40-year-old Asian American divorced woman
Presenting problem:
Mental status exam:
Risk assessment:
DSM
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Short term goals:
Long term goals:
Possible treatment methods:
Medication:
Frederick R., 22-year-old African American single man
Presenting problem
Mental status exam
Risk assessment:
DSM
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Short term goals:
Long term goals:
Possible treatment methods:
Medication:
Roger K., 73-year-old Hispanic widowed man
Presenting problem:
Mental status exam:
Risk assessment:
DSM
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Short term goals:
Long term goals:
Possible treatment methods:
Medication:
Jonathan A., 16-year-old Caucasian male
Presenting problem:
Mental status exam
Risk assessment:
DSM
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Short term goals:
Long term goals:
Possible treatment methods:
Medication:
Traci H., 10-year-old African American girl
Presenting problem:
Mental status exam:
Risk assessment:
DSM
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Short term goals:
Long term goals:
Possible treatment methods:
Medication:
Attachment
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Top of Form Treatment Plan
Bottom of Form |
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Attachment
Treatment Plan Guidelines
Assignment Background
The professional counselor understands the importance of treatment planning when working with clients.
Assignment Instructions
- Review the case history of each client below.
- Develop a treatment plan for one of the clients.
Assignment Requirements
- Correctly incorporate the key issues presented by the client.
- Be sure to address the medical, mental health, social history, substance abuse, legal issues, support systems, strengths, assets, and resources available to the client. Accurately and objectively document this information in the treatment plan.
- Using the DSM, please complete the 5-axis approach to treatment planning. In addressing short- and long-term goals and treatment methods, be sure the treatment methods align with the DSM diagnosis.
- Demonstrate correct application of the DSM 5-axis approach by referencing and providing appropriate citations from the DSM.
- Create 6-10 questions regarding additional information they would want to know about the client (add to the completed treatment plan template).
- Write a 1,000-1,250 word essay from the information you gathered.
- Three to four academic resources are required for this assignment.
Client Case Histories
Allison W.
Allison W. is a 59-year-old, Caucasian, single woman living alone in her family home. She is slightly overweight, but is well-groomed and alert. She lived with both parents until their deaths, and is still actively grieving the loss of her mother although it has been three years since her mother died. At age 35, she hurt her back, was taking Benzodiazepines for muscle relaxation, and needed to detox after six months of treatment. She is in general good health but has anxieties and fears about any medical issues and ruminates about medical test results. Allison admits to researching on the Internet regarding symptoms she believes she is experiencing including racing heartbeat, dizziness, headaches and shortness of breath.
Allison admits feeling tired, unfocused, and stressed. She reports losing track of what she tries to say, and her mind races when she goes to bed. She reports poor sleeping and eating habits.
Allison is an art instructor at a small community college and has many colleagues and friends but no close relatives or significant other.
Sonia B.
Sonia B. is a 40 year-old, Asian American, divorced (for six months) woman living with her 7-year-old son and 4-year-old daughter. She presents a neat and professional appearance and maintains a successful career in middle-level management. Sonia has worked for the same company for over 10 years, but finds herself worrying about losing her job and being unable to provide for her children. She has very high standards for herself and is often self-critical if she doesn’t meet her own expectations. Currently, she is struggling with feelings of worthlessness and shame due to her perceived inability to perform as well as she has in the past at work and at home.
For the past several weeks Sonia has felt very fatigued and found it hard to concentrate at work or involve herself with her children’s activities. Her doctor recommends being assessed for a thyroid condition. Her coworkers have noticed that she is irritable and withdrawn, which is unlike her usually friendly and easy-going personality. Although she denies thoughts of suicide, Sonia has found herself increasingly dissatisfied with her life. She admits to having frequent thoughts of wishing she was dead but worries about how her death would affect her children.
Frederick R.
Frederick R. is a 22-year-old African American single man. Frederick’s appearance is slightly disheveled and he has difficulty maintaining eye contact. He is a computer science major residing in the residence halls at a small private Baptist college. During the past several weeks his family and friends have noticed increasingly bizarre behaviors and Frederick has stopped going to classes. On many occasions he has been overheard whispering in an agitated voice when alone. At this time Frederick insists he is the reincarnation of Jesus.
Frederick occasionally goes to bars with friends, but has never been known to abuse alcohol or drugs. He has a history of childhood asthma that reoccurs on occasion with stress. Recently he had broken up with his girlfriend accusing her of trying to give him drugs and poison him. Frederick’s parents have tried to take him to a psychiatrist for an evaluation, but he refuses because they fail to recognize him as Jesus.
Roger K.
Roger K. is a 73-year-old Hispanic widowed man. He has a fixed income and lives in an assisted living facility following a minor stroke. Roger has partial paralysis on his right side, but has responded well to physical therapy. He presents very friendly, outgoing, and cooperative, but staff and other residents report he can be sullen, forgetful, and even belligerent at times. Roger has a son and two daughters (and several grandchildren) who visit him weekly and take him on outings. Roger walks with a cane and leaves the facility on his own several times a week to go to church. Often it is after these outings when Roger’s behavior appears altered.
Staff and other residents have reported the odor of alcohol on Roger but he has not seemed intoxicated. Roger denies any substance abuse history but does admit to “enjoying a beer sometimes.” He reports he and his late wife had an active social life including dancing and drinking. Roger states he thinks about his wife often and misses her.
Jonathan A.
Jonathan A. is a 16-year-old Caucasian male. He was well-groomed and fashionably dressed. He gave detailed responses showing blatant disrespect for his mother’s opinions. He lives with his mother and two younger siblings in a working-class neighborhood. Jonathan attends Harper High School where he is enrolled in the tenth grade. Until this current year, Jonathan was a good student with an excellent attendance record and was active in several extracurricular activities. Currently he has been truant several times and has failed two subjects in the first semester.
Jonathan’s mother reports Jonathan has made new friends she does not know and is concerned about their influence on her son. He habitually comes home after his set curfew.
Jonathan’s parents have been divorced for two years, and his father has recently remarried and moved out of state. Jonathan denies these changes have affected him, reporting his younger siblings are more affected by the limited contact with their father. Jonathan reports he has never been close to his father. When asked if he is concerned about his failing two subjects, Jonathan replied he didn’t care if he finished school or not as “nothing matters anymore anyway, I’m a failure and don’t fit in.” He presents with no medical problems
Traci H.
Traci H. is a 10-year-old African American girl. She was neatly dressed and groomed and appeared quiet but cooperative during the interview. She lives with her mother and stepfather in a middle-class neighborhood. Traci attends Harrison Elementary school where she is enrolled in the fifth grade. She normally maintains good grades in school and states that she likes school, but her grades have slipped the last quarter. Her mother reports she is concerned that Traci has been more withdrawn lately and not interested in activities she previously enjoyed including her friendships with other girls in the neighborhood. Traci is experiencing nightmares, sleeplessness, and complains of stomachaches and headaches. She has also shown a preoccupation with clothing, grooming, and weight. Neither Traci nor her mother is overweight, but Traci’s mother reports her daughter has been picking at food and refusing to eat certain foods because she “does not want to get fat.” Traci appears tall for her age and her weight seems proportionate to her height, but her mother reports she has not gained any weight in the last six months.
Traci sees her father, stepmother, and two stepsisters weekly. She reports she enjoys these visits. Her mother states at times Traci has told her she prefers not to visit her father’s home.
Jermaine Byrant
Nicole Johnson
OVER
RATING
YEARS
