1) Describe how you assessed the client/family during the first interview. How did you build rapport, etc. Discuss how you integrated any assessment tools? Why did you use these specific assessment tools? (back this up with research) What diagnosis did you give your client and why?
2) Discuss the intervention/counseling approach you are using with the client/family. Provide a rationale for this choice. Why did you choose this approach with this client and/or family? What are the benefits or drawbacks of the approach? Support this choice with the latest research findings.
3) Develop an initial treatment plan based on the intervention and approach you plan to use. Discuss specific goals and objectives and provide justifications. How will you measure and/or monitor these goals and track progress?
4) Provide details regarding at least two sessions and what you addressed with the “client”. This does not have to be a script but just a general summary and description of what your session and conversations were like with the “client” (or family….or both).
For example, you might start off this section with:
“Clinician met with Client for initial session…..” or “Time was spent discussing…..” or “Clinician provided Client with ……….”
There is no “right or wrong” here, you can be creative but you must be thorough and provide justification for everything with research. Always reference what the literature says. Ask yourself WHY?, HOW?, etc.
5) Develop a 90-day treatment plan based on the treatment process “thus far”. Have initial treatment plan goals been met? Have you identified new issues or goals that need to be implemented? Describe the progress (if any) the “client” is making. What factors have contributed to progress? OR, what barriers have played a role in lack of progress. Be creative here too-you are basically creating your client scenario.
Hillary
Hillary presents with concerns regarding
excessive worry and anxiety which she
experiences on a daily basis for at least the
past six months. She finds it difficult to control
her worries and experiences difficulty
concentrating, irritability, and problems falling
asleep. Hillary does not have a history of
mental illness or substance use. Hillary has
always felt anxious or nervous but it seems to
have gotten worse lately.
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