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you make up the info as if you actually did the assessments on someone

You will complete a biopsychosocial assessment report that integrates a mental status examination and the appropriate DSM assessments. This assignment provides opportunities to apply assessment skills.

Tasks:

Part I: Meet with Your Classmate and Conduct a Biopsychosocial Assessment:

  • Conduct your intake session telephonically with your assigned practice client. The client must present as an adult client.
  • The session should range between 45-50 minutes in length.
  • Administer the mental status examination to the client. You can use electronic options (i.e. Skype, Facetime) to complete the Mini-Mental Status Examination (MMSE) if possible.

Part II: Write a Biopsychosocial Report:

Follow the details below pertaining to the report’s requirements.

Your written report should be 3 to 5 pages in length and should follow APA guidelines for writing style, particularly chapters 3 (“Writing Clearly and Concisely”) and 4 (“The Mechanics of Style”). Clear documentation of services is a very important skill that can result in a client’s services being reimbursed or denied; and therefore, unclear documentation could result in a client welfare issue. You should have a title page and a header labeled “Biopsychosocial Assessment Report Your Name.”

A. Biopsychosocial Assessment:

Your biopsychosocial assessment should be written in such a manner that the selected diagnosis is clearly supported by the evidence in the documentation.

A formal mental status examination will be conducted. In addition, the following information should be reflected throughout the report when relevant to the client:

3 As (Appearance, Attention, and Activity Level); Orientation (Xs 4); Motor Activity; Speech and Language; Mood/Affect; Cognition (Thought Process and Content); Memory; Insight and Judgment; Motivation; Risk of Harm to Self; Risk of Harm to Others

Your written assessment should be documented in the following format:

  • Name (Pseudonym) of Client.
  • Age of Client.
  • Referral Source: Include who/how client was referred for counseling services.
  • Presenting Problem: Address why the client decided to seek treatment now. Be sure to include all symptoms that will support your diagnoses (i.e., frequency, duration, severity).
  • History of Presenting Problem: Include the history of the problem (i.e., previous episodes, duration, precipitating factors).
  • Developmental History: Include developmental milestones met and not met; major accidents, injuries, and hospitalizations; and other significant developmental history.
  • Medical History: Include medical illnesses (i.e., chronic, head trauma, etc.) and medication history (i.e. psychotropic, chronic, over-the-counter, vitamins, etc.).
  • Mental Health History: Include mental health diagnoses previously given, treatment received, and treatment outcomes; document traumas, losses, victimization, substance abuse, or other behaviors like gambling, sex, shopping, eating, etc., that might be used to regulate emotion; and document hospitalizations, nonsuicidal self-injury, suicide attempts, or violent behavior toward others.
  • Family History: Include family of origin, current family as the client defines it and sociocultural information that is relevant to treatment. Document the client’s experience of those relationships.
  • Relationship History: Include significant information related to relationships outside of family, such as friendships, dating relationships, work relationships, relationships with co-workers/bosses/teachers, etc.
  • School/Work History: Include successes, challenges, learning disabilities identified, and frequent changes, if any. Include reasons for those changes.
  • Legal History: Ask specifically about open Child Protective Services (CPS) cases or probation/parole/court orders, including divorce/separation decrees. Ask for copies of orders and a release to speak to caseworkers/probation officers, etc., and document that you received them—it is a practice client, so we will assume you actually would get the documents or releases, as necessary.
  • Strengths/Supports: Include hobbies, friendships, current relationships, pets, sports/exercise, spirituality/religion, civic groups, or personal strengths identified during the assessment.
  • Behavioral Observations: Include results from the MSE and additional behavioral observations.
  • Assessment Results: Document the assessments administered and the scores of each assessment.

Submission Details:

  • Your final product will consist of your report in a Microsoft Word document (approximately 3–5 pages in length). Your report should be written in APA format in a clear, concise, and organized manner; demonstrate ethical scholarship in the accurate representation and attribution of sources; and display accurate spelling, grammar, and punctuation.
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