Comprehensive Client Family Assessment

Comprehensive Client Family Assessment
Comprehensive Client Family Assessment
Permalink:
Demographic information
J.S is an 8-year-old, African American/Caucasian, male.
Presenting problem
Mother reports that she and J.S’s father separated in October of 2015. She reports J.S wishes for her and his father to reunite and get back together. She believes that he could benefit from additional support with understanding the separation of his parents. Mother reports since separation J.S is “clingy” as evidenced by wanting to be with mother all the time (e.g., wanting to sleep with mother, wanting to be with mother in the house and not alone in his room). Mother reports J.S talks to her, but is uncertain if he has any suppressed thoughts or feelings. She shared that J.S’s father was recently on the phone with a women while he was visiting. Mother reports since this J.S has been having a lot of questions about whether his parents will be together again and whether they have other significant relationships. She shared that she wants J.S to understand the concept of his parents being apart.
History or present illness
Mother reports onset of Jayden’s behavior occurred in 2015 when her and Jayden’s father separated.
Past psychiatric history
Mother reports none
Medical history
Mother reports none.
Substance use history
Mother reports none.
Developmental history
Mother reports no delays.
Family psychiatric history
Mother reports anxiety and depression on both J. S’s paternal and maternal side of family. Father is struggling with addiction.
Psychosocial history
J.S reports having a lot of friends. He reports getting along with his friends.
History of abuse/trauma
Mother reports none.
Review of systems
Gen: Denies weakness, fatigue, fever, chills, night sweats, heat intolerance.
Head: normocephalic; denies migraine headaches.
ENT: Denies visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty
Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes. Cardiopulmonary: Denies cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, hypertension.
GI: Negative for decreased appetite. Neg for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.
GU: No dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.
MS: Denies backache, joint pain, stiffness. Gait is normal and steady.
Heme/Skin: Denies bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.
Neuro: Denies seizures, paralysis, muscle weakness, parasthesia, sensation changes.
Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.
Physical assessment
Vital Signs:
47 Height: inches
Weight: 115lbs
Temp: 37 C.
RR: 16
BP: 110/62
Pulse: 82 BPM
Appearance: Slender bi-racial male, slightly tan, appearing younger than stated age in distress, no acute distress, neatly dressed and groomed.
Mental status exam
J.S presents to the appointment with his mother. He alert and oriented x4. Neurologically intact. J.S. is neatly dressed. Polite mannerism and very social. Mood and affect is euthymic and appropriate. J.S. is comfortable interviewing with therapist while mother steps out. He seems to like talking to therapist and asks many questions about games, books, etc. that are present in the room. J.S. denies any SI/HI or A/V/H. Speech is coherent and clear. J.S. fidgets with his hands during interview and processed better after therapist offered Play-Dough to figet with instead.
Differential diagnosis
Z63.5 Disruption of family by separation and divorce
Diagnosis
Seperation and Anxiety Disorder
Case formulation
Mother reports that her and J.S’s father separated in October of 2015. Mother reports since separation J.S is “clingy” as evidenced by wanting to be with mother all the time (e.g., wanting to sleep with mother, wanting to be with mother in the house and not alone in his room).
J.S attended session with his mother. He completed a Basic Emotion Assessment indicating mixed emotions (sad, angry, happy, excited). J.S rated sadness as a 4 on a scale from 0-5 with 5 indicating very sad. Jayden explained, “I am sad that my dad does not live with me anymore.” He reported that he is happy and excited because he will be going to his grandmother’s home for the summer.
According to the American Psychological Association (2013), diagnosis assigned to individuals who have an unusually strong fear or anxiety to separating from people they feel a strong attachment to. The diagnosis is given only when the distress associated with the separation is unusual for an individual developmental level, is prolonged and severe. In accordance with J.S.’s intake assessment and individual therapy session, he fits the criteria for this diagnosis.
Treatment plan
Treatment Goals
J.S will acknowledge and accept the separation of his parents. He will begin a healthy grieving process and manage reactions experienced due to disruption of family by separation.
Estimated Completion: 3 Months
Objective #1
J.S will bring awareness to thoughts and feelings related to his parents’ separation as evidenced by (a) identifying and listing emotions surrounding two parents and two homes, (b) clarifying his relationship patterns with his custodial (mother) and noncustodial (father) parent, and (c) participating in expressive art activities or psychotherapy exercises to help express thoughts and feelings about parents’ separation. Progress will be measured per J.S’s report, parent report, and Therapist direct observation.
Treatment Strategy / Interventions: Supportive psychotherapy, integrating psychodynamic, cognitive-behavioral, and interpersonal conceptual models and techniques will be used to address and respond to J.S’s thoughts and feelings related to his parents’ separation.
Therapist will educate J.S on how relationships may begin and end. Therapist will elicit J.S’s exploration, description, and ventilation surrounding the disruption of family by separation. Therapist will assist him in developing vocabulary to express emotions. Psychoeducation, Psychotherapy Homework, Psychotherapy Worksheet, Expressive Arts Therapy will be used to help him identify, list, and bring awareness to his emotions and thoughts. Therapist will help Jayden learn how to rate his emotions using basic emotion assessments each session. Supportive Reflection, Interactive Feedback, Symptom Management, Relaxation/Deep Breathing will be used to foster a therapeutic environment and alliance where J.S is comfortable in sharing.
Estimated Completion: 3 Months
Objective #2
J.S will accept parents’ separation with consequent understanding and control of feelings and behavior as evidenced by (a) practicing emotion regulation skills (e.g., opposite actions, checking the facts, focusing on positive events, etc.), (b) developing and using relaxation techniques (e.g., deep breathing, mindfulness, drawing, coloring, etc.), and (c) learning and verbalizing the stages of loss and grief for children whose parents have separated. Progress will be measured per J.S’s report, parent report, and Therapist direct observation.
Treatment Strategy / Interventions: Therapist will gently explore, confront, and address J.S’s reactions to his parent’s separation. Using DBT and CBT approaches, J.S will be educated, taught, and modeled skills he can use to cope with strong negative emotions. Therapist will help J.S understand the stages of loss and grief experienced by children. Therapist will determine what stage of loss and grief he is in and help him move towards acceptance. J.S will be asked to identify and list the advantages and disadvantages of his parent’s separation. He will be encouraged to focus on positive experiences he has had since his parents’ separation to help him accept and embrace changes. Role-Play/Behavioral Rehearsal, Psycho-Education, Psychotherapy Worksheet, Supportive Reflection, Symptom Management, Interactive Feedback, Exploration of Coping Patterns, Exploration of Coping Patterns, Exploration of Emotions will be used.
Estimated Completion: 3 Months
Social Support system:
Mother, maternal grandmother.
Part 2: Family Genogram
Genogram includes J.S. maternal side of family. Mom reports no knowledge of paternal family members by name.
Grand
Father Ed
Grand
mother Judy
Jade
Father
Greg
Mother
Ashley
Great
grandfather
Tom
Great
grandmother
Ann
Learning Objectives Students will: •Assess clients presenting for psychotherapy • Develop genograms for clients presenting for psychotherapy
To prepare: • Select a client whom you have observed or counseled at your practicum site. • Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.
The Assignment
Part 1: Comprehensive Client Family Assessment With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations): •Demographic information •Presenting problem •History or present illness •Past psychiatric history •Medical history • Substance use history •Developmental history •Family psychiatric history •Psychosocial history •History of abuse/trauma •Review of systems •Physical assessment •Mental status exam •Differential diagnosis •Case formulation •Treatment plan
Part 2: Family Genogram Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).
Required Readings:
(1) Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
ATTACHED WITH THIS HOMEWORK IS A SAMPLE OF THIS ASSIGNMENT AND REMEMBER IT HAS TWO PARTS.
The Hernandez Case Study
Part 1: Comprehensive Client Family Assessment
Demographic information
Juan Hernandez Junior is an 8-year-old, Latino, male.
Presenting problem
Juan Hernandez Junior described a punishment at school that led to them calling the ACS. The school social worker was told of how the Hernandez parents made him kneel on his knees for hours while holding two heavy encyclopedias in each hand as a form of punishment. He reiterated that this punishment had been used on them on several occasions and this led to the ACS sending a worker to their home. The ACS worker thought that the concern was credible since this form of punishment was abusive and suggested that they start attending family sessions and visit the local community mental agency to complete a parenting group.
History or present illness
Past psychiatric history
Parents report that Juan Jr. has been of sound psychiatric health.
Medical history
Parents report that Juan Jr has been healthy. However, his mother has been diagnosed with diabetes recently.
Substance use history
Both parents have no history of substance abuse nor does Juan Jr.
Developmental history
Parents reports no delays.
Family psychiatric history
Parents report no psychiatric problems in their family history.
Psychosocial history
Juan Jr is quite sociable. He and his parents go to the beach and the park near their home on weekends to socialize and play.
History of abuse/trauma
Prior to the current problem that involves the form of punishment that the Hernandez are using on their children, there are no other abuse incidents that Juan Jr. has experienced.
Review of systems
Gen: Has no fever, night sweats, heat intolerance, weakness or fatigue.
Head: No migraine headaches reported.
ENT: No visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty
Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes.
Cardiopulmonary: Patient indicates they have not witnessed any instances of cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, hypertension.
GI: There have been no changes to the patients eating habits. He has tested negative for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.
GU: He also has been cleared of dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.
MS: On the other hand, he has reported no backache, joint pain, stiffness. Gait is normal and steady.
Heme/Skin: Patient insists they have had no bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.
Neuro: No indication of seizures, paralysis, muscle weakness, parasthesia, sensation changes.
Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.
Physical assessment
Vital Signs:
47 Height: inches
Weight: 129lbs
Temp: 37 0C.
RR: 16
BP: 120/59
Pulse: 79 BPM
Appearance: Slender, Latino male who appears his age and no distress observed. He is well groomed and dressed to impress.
Mental status exam
The whole family comes to the appointment since they have to do both family sessions and a positive parenting program for the parents. Juan Senior comes on with a lot of anger and resentment towards the counselor a she sees no point in attending the classes.
Differential diagnosis
The parents grew up too fast and are projecting their feelings on their children.
Diagnosis
Anger Management issues
Case formulation
The Hernandez parents, Juan Senior and Elena are brought for sessions by the ACS as a result of their son’s abuse allegations. Juan Hernandez is a 27 year old Latino man who works as a casual worker at the airport with back problems due to the amount of heavy lifting he has to do on a daily basis. He has no drug abuse problem but a criminal history of juvenile petty theft that has since been expunged. Additionally, he takes approximately six to eight beers every weekend. On the other hand, Elena is a 25 year old Latino woman born in Puerto Rico but raised in New York who was recently diagnosed with diabetes. She has no drug abuse problem nor a criminal history. She drinks 1 or 2 drinks a month.
Treatment plan
Treatment Goals
The weekly parenting classes and family sessions will teach the parents effective and safe discipline skills, the importance of recognizing age-appropriate behavior, managing one’s frustrations, and the child development techniques that boosts child’s self-esteem and their sense of confidence. It will also help the family as a whole come to terms with the situation at hand.
Estimated Completion: 3 Months
Objective #1
The parents will be able to discipline their children effectively and using safe options.
Treatment Strategy / Interventions: This will be done through teaching the parents the most effective and safe discipline skills they can use. These may include techniques such as setting limits like taking away their privileges and using time-out. This can only be successful if the parents fully understand the age appropriate behavior of each stage s they do not cross boundaries and punish them unnecessarily.
Estimated Completion: 3 Months
Objective #2
In the end, the parents should be able to find child development techniques that will boost their children’s self-esteem and ensure they have a strong sense of confidence. They should also be able to manage their frustrations as a family.
Treatment Strategy / Interventions: Through role playing, both the parents and the children are able to find a way to understand the feelings of the other so they can rectify any issues they might have had. This will help ensure order at home is maintained without the need for discipline and that the parents do not put unrealistic expectations on their children.
Estimated Completion: 3 Months
Social Support system:
Friends and family
Part 2: Family Genogram
Genogram includes Juan Hernandez Junior’s family.
References
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
Hernandez Family Genogram
Juan Hernandez Senior (Father)
Juan Hernandez Junior (8 years old) (Son)
Alberto Hernandez (6 years old)(Son)
Elena Hernandez (Mother)

Struggling to find relevant content or pressed for time? – Don’t worry, we have a team of professionals to help you on
Comprehensive Client Family Assessment
Get a 15% Discount on this Paper
Order Now
Calculate the price
Make an order in advance and get the best price
Pages (550 words)
$0.00
*Price with a welcome 15% discount applied.
Pro tip: If you want to save more money and pay the lowest price, you need to set a more extended deadline.
We know how difficult it is to be a student these days. That's why our prices are one of the most affordable on the market, and there are no hidden fees.

Instead, we offer bonuses, discounts, and free services to make your experience outstanding.
Sign up, place your order, and leave the rest to our professional paper writers in less than 2 minutes.
step 1
Upload assignment instructions
Fill out the order form and provide paper details. You can even attach screenshots or add additional instructions later. If something is not clear or missing, the writer will contact you for clarification.
s
Get personalized services with MyCoursebay
One writer for all your papers
You can select one writer for all your papers. This option enhances the consistency in the quality of your assignments. Select your preferred writer from the list of writers who have handledf your previous assignments
Same paper from different writers
Are you ordering the same assignment for a friend? You can get the same paper from different writers. The goal is to produce 100% unique and original papers
Copy of sources used
Our homework writers will provide you with copies of sources used on your request. Just add the option when plaing your order
What our partners say about us
We appreciate every review and are always looking for ways to grow. See what other students think about our do my paper service.
Nursing
Writer went above and beyond. Can't believe how much work they put in for the price.
Customer 452707, July 10th, 2022
Human Resources Management (HRM)
Dynamic!!
Customer 452701, October 17th, 2023
Nursing
Thank you for a great paper.
Customer 452707, August 6th, 2022
Human Resources Management (HRM)
Thanks
Customer 452701, August 15th, 2023
Human Resources Management (HRM)
Excellent
Customer 452813, December 30th, 2023
Human Resources Management (HRM)
Thank you for doing such an awesome job.
Customer 452701, June 30th, 2023
Human Resources Management (HRM)
Well written paper. Thank you so much.
Customer 452701, September 25th, 2023
Human Resources Management (HRM)
Thanks for your time.
Customer 452701, September 10th, 2023
Technology
Great job on the paper!!
Customer 452885, December 14th, 2022
Professions and Applied Sciences
Thank you!
Customer 452707, March 4th, 2022
Nursing
Always on time and a life saver for sure!!!!!!!!!!!!
Customer 452453, October 22nd, 2021
Nursing
As usual, the writers do amazing work.
Customer 452707, October 1st, 2022
OUR GIFT TO YOU
15% OFF your first order
Use a coupon FIRST15 and enjoy expert help with any task at the most affordable price.
Claim my 15% OFF Order in Chat

Good News ! We now help with PROCTORED EXAM. Chat with a support agent for more information

NEW

Thank you for choosing MyCoursebay. Your presence is a motivation to us. All papers are written from scratch. Plagiarism is not tolerated. Order now for a 15% discount

Order Now