Case formulation and treatment plan

Case formulation and treatment plan

Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues.

 

To prepare:

· Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.

· Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.

· View the mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.

 

The Assignment

Document the following for the family in the video, using the Comprehensive Evaluation Note Template:

· Chief complaint

· History of present illness

· Past psychiatric history

· Substance use history

· Family psychiatric/substance use history

· Psychosocial history/Developmental history

· Medical history

· Review of systems (ROS)

· Physical assessment (if applicable)

· Mental status exam

· Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5 diagnostic criteria

· Case formulation and treatment plan

· Include a psychotherapy genogram for the family

 

Note: For any item, you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.

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