Biopsychosocial case history

This assignment requires you to write a thorough biopsychosocial case history of a client with whom you have worked.

Case History (4 pages)

General Instructions: The case history summarizes important background
information used for evaluating a client for treatment. Be succinct in
describing the case history. Use the
bold headings in your report!

Select one of your current or past clinical cases for
this assignment. (If you do not have an appropriate client, please see me.) Provide a fictitious name to protect the
confidentiality of your client. You will use the same name in the two
conceptualization & treatment planning take-home assignments.

Identifying Information
Describe the client’s relevant
demographics, such as age, relationship status, children, present occupational
status, along with a description of appearance, quality of speech, and client’s
attitude toward the interviewer.

Presenting Problem & History of the Problem
Describe the present problem(s), including emotional,
cognitive, behavioral, and physiological symptoms. Note environmental stresses.
Include a history of the problem and the client’s previous efforts to alleviate the problem.

Past Psychiatric History
Briefly summarize past personal and/or family history
of psychiatric or substance-use treatment.

Human Rights
& Social Justice
Briefly describe the intersection of the client’s
presenting problems with issues of oppression or other violations of human
rights.

Current Psychosocial
Functioning
Briefly summarize current functioning related to family/living
arrangements, work/school, financial, medical (including drug use), legal (if
relevant), or other relevant life situation.

Personal and Social History
Briefly summarize personal and social history,
including:
·
Family of origin
(parents, siblings, and significant others)
·
Brief description
of childhood, adolescence, early adulthood
·
Nature of
relationships with parents, siblings, and significant others
·
Traumatic events
during childhood, adolescence, early adulthood
·
Educational/work
history
·
Medical history –
Note any medical problems (e.g., endocrine disturbances, heart disease, cancer,
chronic medical illnesses, or chronic pain) that may influence psychological
functioning or the treatment process.
·
Social
class/cultural history
·
Spirituality/religious
history

Mental Status Observations
Typically includes a
description of the following: general appearance, level of alertness,
quality/style of speech, general behavior, and attitude, orientation (person,
time, place), reported mood, observation of affect, thought process, thought
content, short and long term memory, level of insight, judgment, reasoning,
and communication style.

Strengths and Protective
Factors
Include a statement about the
client’s strengths and protective factors.

Intersection of
Client/Worker Relationship in Developing the Psychosocial Assessment
Discuss how issues of power,
privilege, and oppression were manifested during the assessment process.
Discuss how the client’s identity and demographics intersect with their
problems. Thinking ahead, how might the client’s identity and demographics
affect the development of the formulation? What steps may be taken to safeguard
the client’s dignity, self-worth, and human rights?

Diagnostic Impressions
Provide a general description of symptoms or focus of
the problem, for example, “The client presents with symptoms of anxiety,
especially related to work stressors.”

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