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COU 640 Biopsychosocial Assessment
Client Name_Anessa Chart # _XXXXXX
Evaluating Counselor Shannen Carambia Date _4-17-2020
Please indicate “NA” if the question/section is not applicable to the client’s history. DO NOT LEAVE ANY SECTION/LINE BLANK.
Presenting Problem: (Include the client’s own words about why the services are needed, any referrals, and major stressors over the past six months.) Comment by Edwards, Brenda: Where are client’s own words included?
Anessa hurt her knee during a dancing competition. She was in her senior year when the incident occurred. The pain prolonged through the first several months of college. After having medication from various doctors, it is noted that she misused the prescribed drugs which started affecting her psychological well-being. The mother noted and raised the concern and recommended that she see someone. Some of the reasons as to why Anessa’s mother was concerned are that Anessa was taking up to 15 pills in a day which is drug abuse. Other symptoms are sleeping late, withdrawal from the family, reduced appetite, and distracted from school. Missing information about other symptoms which should be behavioral, cognitive, emotional, and physiological. What is your analysis of the life span for the client for appropriate sexual development? See assignment guidelines and rubric. Comment by Edwards, Brenda: The case study stated there would be a projected recovery time into college not that she was in college. Review the case again. Comment by Edwards, Brenda: In what way? This has to be specific to the problems
Past Treatment History: (Include past treatment history for substance abuse AND mental health services.) Anessa did not disclose past treatment for substance abuse or mental health services???
The first treatment Anessa was Vicodin as pain reliever. The prescription was supposed to last for a month as they were 60 pills. She was supposed to take a max of two pills in a day. Her prescription was refilled again after one month with 60 pills. The medications ended within the first three weeks as she started overdosing. The first week of the second month of prescription she took 2×1. The second week she started taking 3×1 and the third week she moved to 4×1. Comment by Edwards, Brenda: This was medical treatment for her injury not substance abuse???? Comment by Edwards, Brenda: Did she overdose or take more than prescribed?
After the medication ended she was prescribed with 30 OxyContin pills to last a month. The medications ended early and moved to another doctor who prescribed hydrocodone to last for a month. However, she had visited two different doctors and had collected medications to sustain her for six months. However, she consumed all the prescription within a month.
How are you addressing past mental health services?
Family History: (Include biological family members, number of children, divorce, separations; describe what it was like growing up in this family, and include substance abuse and psychiatric history of family members.)
Anessa was brought up in a stable and supportive family. The family supported her to pursue her dreams even from a young age where the sfhe embraced dancing and received many awards. Her father was an African American and her mom was Hispanic. Her dad possessed his limousine commercial while the mother was a house wife and focused on taking care of the children. Anessa was a third born among five children and all the kids were maintained and stimulated to pursue their talents. Was there substance abuse and psychiatric history of family members? Comment by Edwards, Brenda: What does stable mean? Make this specific to her family composition and social status Comment by Edwards, Brenda: ????
Biological history? Illnesses, surgeries, medications
Substance Abuse Drug History: (Include top three drugs of choice.)
1. N/A- there has to be drug used. Pain relievers are opiates
Substance Type |
Age of First Use |
Route of Administration |
Amount Used |
Frequency of Use |
Date of LastUse |
Treatment Where/When |
Alcohol |
N/A |
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Cocaine |
N/A |
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Marijuana |
N/A |
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Heroin |
N/A |
|
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|
Other Opiates Comment by Edwards, Brenda: Anessa is abusing an opiate |
N/A |
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|
BZs |
N/A |
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Methadone |
N/A |
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Suboxone |
N/A |
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Tobacco |
N/A |
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List any withdrawal symptoms as reported by client (sweats, constipation, DTs, seizures, etc.):
N/A
Social History
Client’s Current Life Situation: (Summarize present living arrangements and any current social supports.)
The client lives with the family under the care of her father and mother. There are other four siblings as she is a third born in a family of five. However, there are no other social supports noted.
Sexual Orientation:
N/A
Spiritual Beliefs:
N/A
Employment History
Employment: (Include longest continuous employment, type of employment, typical length of stay, present employment, and military history.)
N/A
Education: (Note highest level of schooling completed, school performance, peer relationships, and learning problems.)
Anessa is a college student as the illness kicked off during the early month on college. She is a student of Juiliard College. She is still in high school. The recovery was projected to last into college review this information for clarity Comment by Edwards, Brenda: ????
Medical Health History: (Include illnesses, surgeries, medications [OTC and prescription]. Note any current medical problems, physical disabilities, and/or eating disorders. Include gynecological history and pregnancies.
The only medical history is the knee injury and the medications given include Vicodin, OxyContin and hydrocodone.
Primary Care Physician:
Name: _______________N/A__________________________________________
Address: _______________________________________________________
Phone: ______________________________ Fax: _______________________
Date of Last Physical Exam: ____________________________________
Hospital of Choice: ___________________________________________
Allergies: ______________________________________________________
Medical Medications: (Include name of medication, dose, condition it is treating, and its effectiveness.)
N/A
Mental Health/Psychiatric History:
Have you ever been treated for a psychiatric illness: Yes or No
N/A
Please explain: (Include if client has been hospitalized, seen by a mental health professional, what they were seen for, and how long they were seen.)
Any SI/HI or plan in past or present? (Please explain if “yes”) this should not be skipped
Psychiatric Medication History:
Drug Name |
Prescriber |
Dosage |
How long have you been taking it? |
Are you currently taking this medication? |
Reason for this medication/diagnosis |
N/A |
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Legal History: (Note any charges and dates, any outstanding warrants, court dates, description of crimes, convictions, incarcerations, etc.)
· No legal issues
· Currently on probation
· Pending warrants
· Jail term served
· Court cases pending
· Parole
Explain with detail any and all of the above checked:
N/A
Clients Self-Assessment of Strengths:
1. N/A Comment by Edwards, Brenda: Review the case and consider her resilience, education, family support
2. ______________________________
3. ______________________________
Clients Self-Assessment of Weaknesses
1. N/A Comment by Edwards, Brenda: Reconsider the case and consider impulsiveness with taking drugs, not asking for help, not using her tenacity and strength to avoid abusing drug
2. ______________________________
3. ______________________________
4.
Recommendations: (This narrative section pulls all of the information together, with a clinical opinion about what the primary issues are and what should be done to address them. Also state potential referrals to rehabilitative, IOP, and so on that are appropriate at this time.)
To eradicate the abuse of drugs the source of the problem needs to be identified. By treating the knee the drug abuse will be eradicated. However she has to be engaged through prescription drug monitoring program. The monitoring program will ensure that the medications are taken as prescribed.
Clinician/Counselor Signature: Shannen Carambia Date: 4-17-2020
Clinical Director Signature: _______________________________________ Date: _
COU 640 Week Seven Assignment Guidelines and Rubric Draft DAP Note
Overview: This assignment is the creation of a draft of the DAP note you will produce for your final project. When you are working in the field, you will need to know how to write a DAP note while counseling clients who show signs of addiction. This is one of the four practice activities that will directly support the final DAP note, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. This activity will be submitted in Week Seven. Prompt: In your draft, make sure to address each of the critical elements below. Remember, this does not need to be a polished artifact, but there needs to be enough information to ensure you are on the right track to submitting the final product in Week Nine. Description
I. Introduction A. Summarize the client. What is the rationale for seeking counseling?
II. Biopsychosocial Summary
A. Describe the problem that brought the client to treatment. i. Make sure to address any problems, issues, or challenges the client may be facing.
B. Explain the symptoms affecting the client. i. What are the behavioral symptoms?
ii. What are the cognitive symptoms? iii. What are the emotional symptoms? iv. What are the physiological symptoms?
C. Identify any environmental factors that may be contributing to the client's problem. D. Identify any potential harmful behavior:
i. Aggression ii. Harm to others
iii. Harm to self iv. Criminal activity v. Impulsive behaviors
vi. High-risk activity E. Determine if the client has a family history of the diagnosis. Consider how this may affect the client. F. Use evidence-based research to support the biological factors presented in the case. G. Outline how the client identifies him- or herself in regard to cultural characteristics. Make sure to add rationale for any answers that are not
straightforward.
i. What are the addressing factors? a. Age and generational influences b. Developmental disabilities (acquired at birth or during childhood) c. Disabilities acquired later in life (e.g., traumatic brain injury, multiple sclerosis, stroke) d. Religion and spirituality e. Ethnic and racial identity f. Socioeconomic status g. Sexual orientation h. Indigenous heritage i. National origin j. Gender
H. Summarize how the client culturally identifies him- or herself. i. With the identifiers above, how does the client culturally identify him- or herself?
ii. What is the order of importance for the client? Assessment
III. Co-occurring Disorders A. Identify any co-occurring disorders. B. Describe the initial DSM diagnosis.
i. What is the overall descriptor of the diagnosis? ii. What criteria must be met to meet the diagnosis?
iii. Describe which client behaviors are being used to meet the diagnostic criteria. C. Discuss the rationale behind the diagnosis.
i. Identify what other diagnoses should be ruled out. Make sure to provide rationale. ii. Identify limitations with this diagnosis. Make sure to provide rationale.
D. Use evidence-based research to support your justification.
IV. Addiction Assessments A. Describe how the assessment was administered. B. Describe the assessment scoring. C. Summarize the assessment results.
i. How do you interpret the results?
Plan V. Recommendations
A. Summarize what you recommend for this client based on the information collected. i. Describe what you recommend for recovery.
ii. Describe what you recommend for relapse prevention. iii. Identify resources you would provide to the client.
Rubric Guidelines for Submission: Consider using the headings from the critical elements outlined above when drafting your DAP note, as you will do this when you submit for your final project. You may also consider using double spacing, 12-point Times New Roman font, and one-inch margins, although none of these specifications are required for the draft version.
Critical Elements Proficient (100%) Not Evident (0%) Value
Introduction: Summary
Provides draft of client summary Does not provide draft of client summary 5.01
Biopyschosocial: Problem
Describes the problem that has brought the client to treatment
Does not describe the problem that has brought the client to treatment
5.01
Biopyschosocial: Symptoms
Explains the symptoms affecting the client Does not explain the symptoms affecting the client 5.01
Biopyschosocial: Environmental
Factors
Identifies any environmental factors that may be contributing to the client’s problem
Does not identify any environmental factors that may be contributing to the client’s problem
6.27
Biopyschosocial: Harmful Behavior
Identify any potential harmful behavior Does not identify any potential harmful behavior 6.27
Biopyschosocial: Family History
Determine if the client has a family history of diagnosis
Does not determine if the client has a family history of diagnosis
5.01
Biopyschosocial: Evidence-Based
Research
Uses evidence-based research to support the biological factors presented in the case
Does not use evidence-based research to support the biological factors presented in the case
5.01
Biopyschosocial: Cultural
Characteristics
Outlines how the client identifies self in regard to cultural characteristics
Does not outline how the client identifies self in regard to cultural characteristics
6.27
Biopyschosocial: Client Culturally
Identifies Self
Summarizes how the client culturally identifies self Does not summarize how the client culturally identifies self
6.27
Co-occurring Disorders: Identifies
any Co-occurring Disorders
Identifies any co-occurring disorders Does not identify any co-occurring disorders 6.27
Co-occurring Disorders: DSM
Diagnosis
Describes the initial DSM diagnosis Does not describe the initial DSM diagnosis 6.27
Co-occurring Disorders: Rational
Discusses the rationale behind the diagnosis Does not discuss the rationale behind the diagnosis
6.27
Co-occurring Disorders: Evidence-
Based Research
Uses evidence-based research to support justification
Does not use evidence-based research to support your justification
6.27
Addiction Assessments: Administered
Describes how the assessment was administered Does not describe how the assessment was administered
4.13
Addiction Assessments:
Scoring
Describes the assessment scoring Does not describe the assessment scoring 4.13
Addiction Assessments:
Results
Summarizes the assessment results Does not summarize the assessment results 4.13
Recommendations: Recovery
Describes the recommendations for recovery Does not describe the recommendations for recovery
4.13
Recommendations: Relapse Prevention
Describes the relapse prevention Does not describe the relapse prevention 4.13
Recommendations: Resources
Identifies resources to support the client Does not identify resources to support the client 4.14
Total 100%

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