Complete the Biopsychosocial Assessment based on the

Jessica case study

and include a case conceptualization in 350 words.

Research common treatment goals for the client diagnosis.

Complete the Treatment Plan, located on the College of Social and Behavioral Sciences Resources page. 

Include a minimum of 2 sources to support your treatment plan.

Format your reference page and treatment plan consistent with APA guidelines.

CCHM/558 v2

Title

CCMH/558 v2

Page 2 of 2

Case Conceptualization Scenario

Jessica

Jessica is a 25-year-old single female having difficulty with high anxiety, fears of getting close to people, feeling the need to be constantly perfect, and she states that she is unable to simply relax. Her sleep patterns are erratic, and she often wakes up in a panic with nightmares about her past. This is your first session with Jessica, and she shares that she was in an abusive situation at her elementary school from grades 1-7. It was a small rural area school with only 1 teacher and less than a dozen students. Everyone was abused and threatened, but she suffered the physical beating more often and more brutally. She reports that she had broken bones, black eyes, and needed stitches in her head a couple of times. She and the others at the school never reported what was really happening until she was in 7th grade and finally told her parents. Her teacher was arrested and imprisoned with a 16-year sentence and the school was shut down. She doesn’t understand why she continues to have difficulty sleeping, eating, and getting close to people when her parents did everything right after the abuse was exposed and her life has been very good.

During one session, Jessica is well groomed, dressed in business attire, and her hair and makeup are perfect. She makes good eye contact during her initial session, and she is logical and coherent in telling about the past; however, she begins to close her eyes and hangs on to the chair in your office tightly, as if it were moving. She cries, sobs, and cannot catch her breath for a few moments. She begins shaking and appears dazed. You say her name a few times, and she opens her eyes, calms her breathing but continues to sob. Jessica continues with telling you that she has a bachelor’s degree in marketing, a high-paying job in a large company, and a supportive family. She has a boyfriend who wants to get married, but she is afraid to commit to him because she feels like she is “too much work”. She states that she does not think she is worth close friendships or love because she cannot give enough back. She avoids most relationships and tries to just be perfect at work and through her diet and exercise. She knows that her background has created this belief but does not have the ability to change it. She shares that in her early 20’s she drank too much too often but has given that up and has been sober for 3 years.

Her reason for coming into counseling is because her family and her boyfriend want closer relationships with her, but she keeps pushing them away. She wonders if there is something that she could do so her relationships could become closer and healthier.

Copyright 2020 by University of Phoenix. All rights reserved.

Copyright 2020 by University of Phoenix. All rights reserved.

College of Social Sciences

Master of Science in Counseling

Biopsychosocial Assessment

NAME(S):

DATE OF BIRTH:

PRIMARY LANGUAGE:

REFERRED BY:

INTAKE DATE:

EVALUATED BY:

DESCRIPTION OF CLIENT(S):

Write what you observe about the client—age, sex, ethnicity, appearance, behaviors, and impressions.

PRESENTING PROBLEM:

Describe the problem as the client has presented it, including perspective, function impairment, and symptoms.

HISTORY OF PROBLEM:

Describe the course of the problem and specific onset and symptoms.

MENTAL STATUS:

Activity:

Mood and Affect:

Thought Process, Content, and Perception:

Cognition, Insight, and Judgment:

Suicidal and Homicidal Assessment

If a more thorough suicide/homicide evaluation is conducted, it may be documented in a separate section.

SOCIAL HISTORY:

Describe the client’s present living situation:

Family:

School:

Health:

Occupational/Work:

Spiritual/Religious:

Legal:

Social History (include history of abuse/trauma):

HEALTH & WELLNESS HISTORY:

Substance use
(including alcohol, drugs, tobacco and caffeine intake)
:

Sleep habits:

Exercise habits:

Eating habits and appetite:

PREVIOUS THERAPY / PSYCHIATRIC SERVICES:

Have you ever been in counseling before? No Yes, Inpatient Outpatient Day Treatment

Name of Provider Clinic Year Diagnosis / Problem

_____________________________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________

Have you ever seen a Psychiatrist before? No Yes, Inpatient Outpatient Day Treatment

Name of MD: _______________________________________ Clinic: _____________________________

Was any of your previous therapy related to substance abuse? No Yes

Have you ever had serious thoughts of suicide or homicide? No Yes

Have you ever made a suicide / homicide attempt? No Yes Explain: ____________________________

_____________________________________________________________________________________

Do you presently feel suicidal or homicidal? No Yes Explain: __________________________________

FAMILY RELATIONSHIP HISTORY:

Describe the client’s current and historical family status and relationships, including during childhood/adolescence.

STRENGTHS:

Describe assets that will facilitate progress and change, such as motivation, intelligence, self-discipline, and willingness to utilize resources.

CHALLENGES

Describe aspects’ of the client’s life circumstance that may impede progress/change, such as homelessness, major psychiatric disorder, financial hardship, etc.

DIAGNOSIS:

Using the information gathered thus far, make a diagnosis using DSM 5.

DISCUSSION/CLINICAL FORMULATION:

Provide your rationale for the provided diagnosis. Describe the appropriate theory to consider using with this client. Note the basics of this theory and how it might apply to this client.

_________________________________________________ __________________

Student/Counselor in Training Date

_________________________________________________ __________________

Supervisor Date