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What do you see as the client’s presenting concerns/basic conflicts?

Title of Assignment

Name

Course and Section

Title of Paper

Every paper you write should start off with a title heading that services as an introduction to the paper. The introduction should be 3-5 sentences.

Presenting Concern

You will likely need to write about one full page or more (depending on your writing style) to fully address each question below. I would suggest including one paragraph per question. Start each paragraph off with a transition sentence that includes words from the rubric or question that you will be addressing in that paragraph (this will make it clear to the reader where you are addressing each prompt and rubric point). After you address the questions, remember to delete the question. Then review your work against the Rubric and “grade” your own paper to ensure you addressed each point. Remember to delete the screen shot of the rubric prior to submitting. Remember to utilize your sources to support your ideas as appropriate and follow APA guidelines. Proof read twice.

Identify which of this week’s theoretical approaches you will use to conceptualize the case and why.

What do you see as the client’s presenting concerns/basic conflicts?

Based upon the concerns you identified, discuss which you would address first and why based upon the theoretical approach.

One Central Concept

You will likely need to write about one full page or more (depending on your writing style) to fully address each question below. I would suggest including one paragraph per question. Start each paragraph off with a transition sentence that includes words from the rubric or question that you will be addressing in that paragraph (this will make it clear to the reader where you are addressing each prompt and rubric point). After you address the questions, remember to delete the question. Then review your work against the Rubric and “grade” your own paper to ensure you addressed each point. Remember to delete the screen shot of the rubric prior to submitting. Remember to utilize your sources to support your ideas as appropriate and follow APA guidelines. Proof read twice.

Identify one central concept of the approach (other than any you previously use to answer the above question) and describe the central concept

Explain how the central concept is relevant to working with the client or understanding the case.

One Technique

You will likely need to write about one full page or more (depending on your writing style) to fully address each question below. I would suggest including one paragraph per question. Start each paragraph off with a transition sentence that includes words from the rubric or question that you will be addressing in that paragraph (this will make it clear to the reader where you are addressing each prompt and rubric point). After you address the questions, remember to delete the question. Then review your work against the Rubric and “grade” your own paper to ensure you addressed each point. Remember to delete the screen shot of the rubric prior to submitting. Remember to utilize your sources to support your ideas as appropriate and follow APA guidelines. Proof read twice.

Identify one strategy or technique you could use with the client and describe the strategy or technique

Discuss why you chose the technique for use with this client.

Dialogue

Provide an 10×10 (or longer) practice dialogue (10 counselor statements and 10 client statements) to give us a brief snap shot of how you would go about using the above strategy or technique. See the attached skills guide for some basic counseling skills that can assist you when implementing the selected strategy or technique.

Explain how successful you felt your 10 x 10 sample was and identify what counseling skills you wish to improve in your CNDV 5310 skills class that you will take in the future.

Reflection

You will likely need to write about one full page or more (depending on your writing style) to fully address each question below. I would suggest including one paragraph per question. Start each paragraph off with a transition sentence that includes words from the rubric or question that you will be addressing in that paragraph (this will make it clear to the reader where you are addressing each prompt and rubric point). After you address the questions, remember to delete the question. Then review your work against the Rubric and “grade” your own paper to ensure you addressed each point. Remember to delete the screen shot of the rubric prior to submitting. Remember to utilize your sources to support your ideas as appropriate (you likely won’t need to use a source in this reflection section) and follow APA guidelines. Proof read twice.

Provide at least one example of how you could apply any strategy, technique, or concept of this theoretical approach to an area of your life to learn something about yourself personally. Also, explain what you learned

What challenges did you encounter when attempting to apply an aspect of this theoretical approach to your life? Provide at least one example.

Did you notice any cultural limitations/obstacles to applying this approach to your life? Describe the cultural limitation or explain how the approach is culturally responsive.

References

Tip: if you used the textbook as a source, look in the syllabus to see how it is cited.

Most of you will likely have used a journal article as your second professional source. See APA Owl Purdue for some citations tips. https://owl.english.purdue.edu/owl/resource/560/07/

Remember to start the references section on a separate page.

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Norms for the public venue and civic context in which you are presenting

DirectionsPart 1: Proposal and Presentation Plan (approximately 1,000 words)

You will draft your proposal and your plan for communicating it prior to beginning to create the presentation itself to ensure you are establishing a clear narrative for your audience. Your mentor has also requested that you provide an analysis of your audience and how you will be addressing them (i.e., the location and format) to ensure that your presentation is suitable for this audience. This will ensure your mentor can provide you the best possible feedback.

  1. Complex Issue: Select a complex issue from the provided list. Describe the “who” and “what” behind the issue you have selected so that your mentor can provide you feedback on the appropriateness of how you’ve situated the problem and your proposal for addressing it for your audience:
  • Issue explanation
  • Sociopolitical and historical context of the issue
  • Importance to the stakeholders in impacted community
  1. Annotated Bibliography: Remember, your mentor has been very clear that an appeal to your audience’s passions is not sufficient in addressing your complex issue. Provide research and evidence that supports your explanation of the complex issue and your recommendations around this issue:
  • Use relevant and credible sources that represent a variety of perspectives
  • Explain how sources inform potential and logical next steps based on resources
  1. Your Position and Course of Action: Next, address the “why” behind the issue in your proposal ensuring you:
  • Explain your position on this issue
  • Describe a logical course of action or actions aligned with your proposal and supported by evidence
  1. Audience Analysis: Lastly, look carefully at the “who” again and “where.” Potentially there will be individuals in your audience from diverse cultures aside from your primary audience. Discuss the following and how you will ensure your visuals and verbal or text narrative will address:
  • Norms for the public venue and civic context in which you are presenting
  • Communication strategies appropriate in addressing your primary audience
  • Communication strategies appropriate in addressing multicultural audiences that differ from your primary audience (for example, are there linguistic preferences or nonverbal signs that would be preferable or not preferable?)

Part 2: Proposal Presentation (10–15 slides with speaker notes in slide deck, or 15-minute video with transcript)

Now that you’ve completed your plan and have a concrete approach around your idea, you feel even more confident about communicating your position! You have many choices for presenting yourself (slide deck with speaker notes or video with transcript). You know your choice will be the “how” behind communicating your position. Your choice of vehicle (slide deck or video) and the information you include in the speaker notes or transcript must address all of the following:

  • Presentation of Issue: Set the stage for your audience:
  • Situate your issue by clearly identifying it
  • Briefly describe the sociopolitical context (local, regional, national, or global)
  • Recommendation: Ensure you concisely and clearly cover:
  • Main Idea
  • Call to Action
  • Communication of Explanation: Ensure you are using your speaker notes or video narration/transcript to ensure your narrative:
  • Aligns to the norms of the public venue in which you are presenting
  • Addresses cultural needs and expectations of the group
  • Appropriate Practices: Use conventions that are:
  • Appropriate to persuasive argument
  • Suitable for a variety of cultural backgrounds
  • Necessary to avoid communicating bias, either intended or unintended
  • Articulation of Response: Clearly convey meaning, demonstrating an understanding of audience and purpose:
  • Correct grammar
    • Avoid slang and jargon
  • Sentence structure
  • Spelling

What to Submit

Every project has a deliverable or deliverables, which are the files that must be submitted before your project can be assessed. For this project, you must submit the following:

  1. Proposal and Presentation Plan (approximately 1,000 words)Draft your proposal and your plan for communicating it prior to beginning to create the presentation itself to ensure you are establishing a clear narrative for your audience. Your mentor has also requested that you provide an analysis of your audience and how you will be addressing them (i.e., the location and format) to ensure that your presentation is suitable for this audience. This will ensure your mentor can provide you the best possible feedback.
  2. Proposal Presentation (10–15 slides with speaker notes in slide deck, or 15-minute video with transcript)Choose a vehicle (slide deck or video) and include information in the speaker notes or transcript. Your choice will be the “how” behind communicating your position.

Please help me to add the following feedback to my paper. 

Complex Issue: Describes a complex issue that is of importance to impacted community supported by sociopolitical and historical context

Criterion Feedback

9/27/23 – Niovy, the feedback provided on 9/21 has yet. to be applied.  Again, please incorporate some additional insights to frame the sociopolitical context and there should be substantive research to support your analysis. With the historical context, it is not clear which events have contributed to the problem or what was the catalyst that created a need to examine this issue further. Why did food insecurity become such an important focus? Why did we start to consider this issue? Does it date back to the conditions after the war or during the Great Depression? Is this a newer challenge that arose after a specific series of events? Identify the events and incorporate research for support. In examining the sociopolitical context, think about who is impacted most. Are there certain geographic locations experiencing more issues with food insecurity than others? Are specific populations more affected than others? What research can be used to substantiate your evaluation?

09/21/23 – Niovy, you are making good progress; however, you need to incorporate some additional insights to frame the sociopolitical context and there should be substantive research to support your analysis. With the historical context, it is not clear which events have contributed to the problem or what was the catalyst that created a need to examine this issue further. Why did food insecurity become such an important focus? Why did we start to consider this issue? Does it date back to the conditions after the war or during the Great Depression? Is this a newer challenge that arose after a specific series of events? Identify the events and incorporate research for support. In examining the sociopolitical context, think about who is impacted most. Are there certain geographic locations experiencing more issues with food insecurity than others? Are specific populations more affected than others? What research can be used to substantiate your evaluation?

Annotated Bibliography: Describes relevant and credible resources representing a variety of perspectives, and how those resources support your explanation of this complex issue

Criterion Feedback

9/27/23 – The feedback provided on 9/21 has yet. to be applied.  Again, please include at least three annotations (you currently have two, but need to incorporate an additional source). Also, include an analysis of credibility and relevancy for each source using the guidance from the previous feedback.

09/21/23 – Again, good work, but the previous feedback has not been fully incorporated. Given the complexity of your topic, please include at least three annotations (you currently have two, but need to incorporate an additional source). Also, include an analysis of credibility and relevancy for each source using the guidance from the previous feedback.

9/2/23 – Niovy, you are off to a great start in this area as well!  But take another look as your annotated bibliography.  You will need to include at least three (3) sources and address each of the elements below:

Clearly evaluate each of your sources against these five (5) criteria:

Authority: Authority refers to the credibility of the author or creator of the information. A person with authority is an accepted expert in his/her field.

Accuracy: Accuracy refers to how factual the source is. An accurate source has reliable references to back up its claims – references that can be verified.

Currency: What is current varies from subject to subject. Medical research relies on a shorter time period for currency than literary or historical studies.

Relevance: Is the source really relevant to your topic? Does it strengthen your argument? Some sources may only relate to your topic in a loose way, especially topics with multiple subcategories.

Objectivity: The point of view and purpose of a source can help you determine how objective a source is and how much bias plays a role

Please address the criteria, for every source in this section, and clearly state why it meets or does not meet that criteria by asking these questions.

Are the authors an authority? Why or why not?  

Is the information presented factual? Why or why not? How do you know?

Is the information current? Why or why not?

Is the source really relevant to your topic? Does it strengthen your argument?  

Is the point of view objective?

08/24/23

You have a good start to compiling the entries for your annotated bibliography. For your next submission, you must have at least three entries.  

The annotated bibliography provides the research foundation for your challenge and helps to guide your position around the topic. To achieve mastery, please ensure your annotated bibliography is in the appropriate format, which will help to analyze the credibility of your sources.  

Project Resource: https://owl.purdue.edu/owl/general_writing/common_writing_assignments/annotated_bibliographies/annotated_bibliography_samples.html

Each entry needs to include these elements:

-Identifying the source authors and discussing their place in society. You need to state information about the author’s education and career background. What makes them an ‘expert’ in this topic? This should be stated in the introduction to the article. Sometimes this is listed at the conclusion of the article.

-Discussing the purpose of the piece and why it was written.

-Explaining the value or ideas behind the content in the source.

-Addressing the credibility of the piece (why or why not). You need to determine if the author based the article on credible, cited research – look at the Reference list of resources. For example – if it is a blog and just based on opinion, this may be useful information but is not as credible. If you use a blog, you need to note that is or is not research-based.

Your Position and Course of Action: Explains your position on the issue and course of action or actions aligned with that position and supported by evidence

Criterion Feedback

9/27/23 – The feedback provided on 9/21 has yet. to be applied.  Again, please fully discuss the course of action and your plans. For example:

First, I propose XXX, which is aligned to the research by Smith (2019); Second, I propose xxx. This will allow you to fully discuss the course of action and your plans.  As you develop each course of action, consider how to implement each recommendation, which will guide how you structure each action. A very important aspect of this area is to include supporting rationale. Please be sure to provide significant supporting evidence for each course of action, which will be evidenced by the use of in-text citations and significant discussion of how the recommendations align to the research.

09/21/23 – You are heading in the right direction, but as stated in the previous feedback, more is needed to address this area fully. It is important to keep in mind that courses of action are recommendations that can be implemented to address the issue. Additionally, it may be helpful to format the courses of action similar to the following. First, I propose XXX, which is aligned to the research by Smith (2019); Second, I propose xxx. This will allow you to fully discuss the course of action and your plans.  As you develop each course of action, consider how to implement each recommendation, which will guide how you structure each action. A very important aspect of this area is to include supporting rationale. Please be sure to provide significant supporting evidence for each course of action, which will be evidenced by the use of in-text citations and significant discussion of how the recommendations align to the research.

First I propose X (action/solution), according to Y (source) this is beneficial…

Second….

Third…

Fourth…

Fifth…

Use the “Interactive: Methods Map” found in the Unit Resources under Research Methods and Research Methodologies to review methods and problem-solving approaches to consider when addressing the recommendations for a given research question or complex challenge. The “Website: Reading Scientific Research” found under the Unit Resources under Research Methods and Research Methodologies presents a strategy for quickly locating key information in scientific research articles. In the Unit Resources: Evaluating Sources: “The Importance of Relevance Sources” explores the importance of relevance related to sources found throughout the research process.

08/24/23

You have a good start to this rubric item. For your next submission, you need to explain why this civic issue is important to you and why you chose this issue for your proposal.

The course of actions identified are good strategies; however, be sure to discuss how the evidence listed supports the identified course of action(s). This will be evidenced by the use of in-text citations and significant discussion of how the recommendations align to the research.  Provide a brief summation or overview of how the source supports the course of action. This will provide credibility to your recommendations.

As you develop each course of action, consider how to implement each recommendation, which will guide how you structure each action. A very important aspect of this area is to include supporting rationale.  

Consider putting in your proposal a well-laid out plan that has recommendations supported by the sources that you have researched.  This will provide credibility to the recommendations as well as show how each connects to the research. For example:

First I propose X (action/solution), according to Y (source) this is beneficial…

Second….

Third…

Fourth

Fifth…

Presentation of Issue: Provides brief description of the sociopolitical context to situate your issue and provide context for your audience

Criterion Feedback

9/27/23 – Same here, the feedback provided on 9/21 has yet. to be applied.  Again, please incorporate some additional insights to frame the sociopolitical context and there should be substantive research to support your analysis. With the historical context, it is not clear which events have contributed to the problem or what was the catalyst that created a need to examine this issue further. Why did food insecurity become such an important focus? Why did we start to consider this issue? Does it date back to the conditions after the war or during the Great Depression? Is this a newer challenge that arose after a specific series of events? Identify the events and incorporate research for support. In examining the sociopolitical context, think about who is impacted most. Are there certain geographic locations experiencing more issues with food insecurity than others? Are specific populations more affected than others? What research can be used to substantiate your evaluation?

09/21/23 – Unable to provide feedback. Presentation was not included as part of this submission.

9/2/23 – Same here, you are off to a really good start but need to situate your complex challenge by incorporating more background insights from the research. More is needed to understand the sociopolitical and historical contexts that impact the issue.  

Sociopolitical Context

Is this issue a recent issue or did a specific event contribute to more stressful work environments (i.e. Financial Collapse, Great Depression)? Additionally, as you consider the sociopolitical aspects, consider the following questions. Does the challenge impact specific industries, cultures, or occupations more than others?  Is this a global, regional, or national issue? Be sure to cite your sources as you incorporate these insights from the research.  

Historical Context

More is needed for the historical context is to show how over time this challenge initiated and evolved to being an issue today.  For example if you were focused on climate change you would be able to trace back to 1800s, human activities became the main driver of climate change, primarily due to the burning of fossil fuels (like coal, oil, and gas)…in 19XX the auto industry added to the emissions issue, 19XX when more factories were being built, 20XX presented a rise in housing developments; cutting down forests to create new homes or commercial properties, or for other reasons.

That historical context is needed to show a longitudinal advancement of the issue over the course of time.  Having multiple instances/dates in history help tie the cause and effect in a way that helps to explain why your topic is so important to your audience.

08/24/23

The revisions requested for your proposal will also need to be done for your this rubric item in your slideshow.

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Which psychological and/or psychiatric problems is this patient presenting with?

MENTAL DISORDERS ASSIGNMENT
MMH21APT
You are expected to submit your assignment individually.

  1. ASSIGNMENT FORMAT
    Your whole assignment consists of a case study, around 2800 (+ 5%) words. The case study is expected to follow these guidelines (as applicable & relevant) and referenced as per university regulations:
    ? A table of contents
    ? List of Acronyms/List of Tables/Figures (if any)
    ? Questions as laid out for each case study
    ? Appendix (if any)
    ? List of references
    1.1 REFERENCES
    All work should be properly referenced using the Harvard referencing style and uniform throughout. Plagiarism should not exceed 20%.
    1.2 FORMAT
    Font: Arial Size 12, Bold for subtitles. Titles in bold and 1 to 2 fonts larger, text justified.
    Line Spacing: 1.5
    For each case study, a total of 5 marks will be allocated to the format, structure, clarity of ideas, critique, and referencing.

Case Study 1
The patient, Christopher, is a 45-year-old Mauritian male of African origin who entered treatment voluntarily at Centre Idrice Goomany which is an urban residential substance use treatment centre in Plaine-Verte.
Presenting complaints
Christopher reports that he relapsed to substance use 8 months ago, and his primary drug of choice is crack/cocaine accompanied by frequent alcohol use. He reports that he had success in treatment for the first time after he was released from prison 4 years ago, and he would like to try and get back on track, as he has hit a low point in the past few months. At the time of treatment entry, Christopher reports no stable living arrangement and had recently been splitting time at the homes of his friends, ex-girlfriend, and uncle. He has four children between the ages of 10 and 27, with three separate women, and has intermittent contact with each of them. He reports that his eldest son, was murdered 5 months ago in a drug-related incident. In his current environment, he reports spending most of his time with old friends, with whom he re-established a relationship with after he was laid off from his job 9 months ago.
History
Christopher was raised by his mother and never met his father. He reports an extensive family
history of substance use, including heroin and crack/cocaine use by his mother, who passed away 10 years ago. Christopher dropped out of high school after Grade 9 (Form III). Between the ages of 18 and 40, he was arrested and spent time in prison multiple times for charges related to theft and possession of marijuana and cocaine. He was released from his last prison term at the age of 41. He has worked primarily as an assistant electrician over the course of his life, but he refused to provide additional details regarding his employment history. His most stable employment history has been during the past 4 years after completing a court-mandated treatment at Centre de Solidarité in Solitude, a residential substance use treatment facility. He reports that he was committed to “turning my life around” at this time, and he successfully remained abstinent until approximately 8 months ago.
Clinical interview
During the interview, Christopher displayed psychomotor retardation, clear thought processes, and no obvious perceptual abnormalities. His speech volume and tone were within normal limits, yet his speech rate was somewhat slower than normal. He reported past crack/cocaine and alcohol dependence beginning at age 16. He reported feelings of depressed mood most of the day, nearly every day, markedly diminished interest in almost all activities, feelings of worthlessness and excessive guilt, and a diminished ability to think or concentrate.
Following the loss of his job, he reported that he had a lot of free time and got bored easily. He felt worthless that he couldn’t find a job and often ruminated over the guilt he felt about his choices in life and his inability to provide for his family. He contacted his old friends, which was soon followed by cocaine and alcohol use. He also reported feeling lonely, guilty, and worthless following the loss of his son, and drug use helped him “get rid of” these feelings, although they would always resurface when he was sober, leading to a cycle of negative reinforcement. Finally, he reported intensifying feelings of sadness and shame that he had used crack/cocaine and alcohol again given how much progress he had made following his release from prison. He felt that he had let his family down, as he was just starting to re-establish relationships with his children before his relapse.
Answer the following questions pertaining to the case study 1 above. Kindly note that a total of 5 marks will be allocated to the format, structure, clarity of ideas, critique, and appropriate referencing.
[5]

  1. Which psychological and/or psychiatric problems is this patient presenting with? Indicate the relevant DSM 5 diagnoses and codes and justify your answer.
    [5]
  2. From which other problems would you need to differentiate, and what are the criteria for doing this?
    [5]
  3. Are there any assessment procedures or instruments you would use to establish the nature or severity of the problem(s) for treatment plan? Justify your answer.
    [5]
  4. Which research-based models are available to explain the nature, aetiology or maintenance of the problem(s)? How do they apply in this case?
    [5]
  5. Is there any other information a mental health practitioner dealing with this/these problem(s) should know about? Justify your answer?
    [2]
  6. Is there any other information this patient should know about regarding his struggles? Justify your answer?
    [3]
    Total Marks = 30

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create a website for an existing product presenting the product as if you created it yourself and you own the business.

Assignment details: Fictional Company Website (for a real product)– create a website for an existing product presenting the product as if you created it yourself and you own the business. 

You will create a multi-page company website with the following pages:

Every Page on your site needs:

·        Title

·        Heading

·        A link back to the homepage (except the homepage which needs links to every other part of the site.

Index.html – this will be the default landing page –

·        it should have links to all of the other pages

·        an image of your product

·        a heading that suggests using a promo code for some % off.

·        A link back to the homepage (index.html)

Our Product – information about your

·        It should include an underordered list of your products features

·        A paragraph explaining the purpose of your product

·        Should include an embedded youtube video that is either a review or advertisement for you product.

·        A link back to the homepage (index.html)

About US – discuss your background – pretend you invented this and you are the CEO

·        Include a picture of yourself

·        A paragraph with your fictional background with a story of how you invented this product

·        A paragraph explaining what you did before inventing this product (who did you work for…where did you attend school etc. Place a div around this paragraph and give it the class name “mystory”. In your CSS file, make the mystory class and create a rule that sets the font to be italic.

·        A link back to the homepage (index.html)

Pricing – Should include a table with pricing for various versions of the product. 

·        You must include at least 3 different versions of the product

·        The price for each version of the product

·        A working link where you can purchase the product

·        You should set the ID of the row with the best deal as the id name “bestdeal” (you will need to create the best deal id later on in your css file

·        A link back to the homepage (index.html)

Style.css – make your style sheet and make sure that all of your pages are linked to it

·        ID named bestdeal should set the background color to a different color and should change the font to bold

·        Class named mystory should set the font to be italic

·        A rule that sets all links to be the color SeaGreen

·        A rule that changes font of all the pages body to Arial

·        A rule that sets the heading of all pages to be #0000DD

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History of Presenting Illness (HPI):

Choose 2 psychiatric patients and complete below with each patient

Subjective:

Chief Complaint:

History of Presenting Illness (HPI):

Past Psychiatric History:

Past Medical History:

Social/Developmental History:

Allergies:

Objective:

Mental/Functional:

Mental Status Examination:

Appearance:

Orientation:

Speech/Language:

Mood:

Affect:

Thought Content:

Insight:

Judgement:

Suicidality & Homicidality:

Assessment:

DSM-V Diagnoses:

Risk Assessment:

Vital Signs:

Height/Weight/BMI:

Plan and Recommendation:

Supportive psychoeducation:

Safety Plan:

Medications:

Follow-up:

SAMPLE

SUBJECTIVE

Chief Complaint: “ I feel depressed and sad.”

History of Presenting Illness: Ashley and her mother presented for initial evaluation. She reported struggling with depression since September of 2018. She described her depression as sadness, irritability, lack of motivation and interest. She feels overwhelmed and easily agitated. She also feels anxious and panic attacks sometimes. She reported lack of appetite some times. Mother reported Ashley cries for no reason. She would tell mother that she cries for no reason. Mother got concerned about this. She then took her to the Doctor who referred her to the hospital. Ashley did well at school with report card of A’s, B’s, C’s. She also reported difficulties with attention and focus. She gets distracted easily. She struggles with completing class and home. Mother reported since she started 8th grade, Ashley has been struggling.

Past Psychiatric History: No hospitalization. She is not in therapy. She is has not been on medications. No drugs or alcohol use.

Medical History: No past medical history has been documented for this patient.

Psychiatric Family History: No family history of mental illness.

Social /Developmental History: Ashley lives with her parents and her siblings. Mother described her pregnancy as normal. She weighed about 6 pounds 6 ounces. Her developmental milestones were normal. No abuse or neglect. Ashley is going into the 8th grade in regular education.

Allergies: No known allergies

OBJECTIVE

Mental/Functional:

Normal

Mental Status Exam:

Appearance: Attire was casual; adequate hygiene and grooming

Orientation: Oriented to person, place, time, event/situation

Speech/Language: Clear; spontaneous, normal rate; normal prosody

Mood: “I feel sad and depressed”

Affect: congruent

Thought Content: No obsessions/compulsions; no evidence of perceptual disturbances

Insight: Good

Judgment: Good

Suicidality and Homicidality: Denies

ASSESSMENT

DSM-5 Diagnoses:

1) ADHD, predominantly combined type

2) Generalized anxiety disorder

3) MDD, RE, moderate

Risk Assessment: The patient denies SI/HI and/or behaviors, intent, and/or plan. Current protective and risk factors were reviewed, and the patient is not currently at clinically significant risk for suicide/homicide. The patient acknowledged understanding of emergency resources such as going to the ER or dialing 911 if experiencing suicidal/homicidal ideation.

Vitals:

Ht: 5’0”

Wt: 132lbs oz

BMI: 25.78

PLAN AND RECOMMENDATION:

1) Supportive psychoeducation completed

2) Safety plan discussed

3) Medications:

– No prescription today. Consider medications after completing the forms.

Complete Conner’s Scale provided for teachers and parents.

Complete baseline EKG

Overall treatment plan was discussed with the patient. Patient voiced understanding.

Continue to require outpatient treatment and medications.

Risks, benefits, side effects, and alternative treatments regarding prescribed medications were discussed with the patient/family. Patient expressed understanding and provided informed consent to be on aforementioned medications.

Rechecks with PCP for further evaluation and treatment of medical problems. Patient voiced understanding.

Patient was advised to immediately return to clinic, call 911, or go to the nearest ER for worsening symptoms, side effects, thoughts of harming others, or any concerns. Patient verbalized understanding.

Referrals: Psychotherapy encouraged

Next Follow-up: 4 weeks or sooner if needed

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