BIOPSYCHOSOCIAL EVALUATION (HN0031- HN) Date of Report

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BIOPSYCHOSOCIAL EVALUATION FORM 8

BIOPSYCHOSOCIALEVALUATION (HN0031- HN) Dateof Report:Sept5, 2016

Section1 – Client Identifying Information

FredRichards SS#:None

MedicAid#:NoneDateof Birth:5May 2001Gender: Male Female

Address: 1940N Mill St, Jackson. Ethnicity:African-American Zip:MS39202

Religion:Christian City: Jacksonville

Section II- Guardian Information

Name:VivianRichards Relationshipto client:Mother

Address: 1940N Mill St, Jackson Phone(Home):+1-202-555-0156

City:Jacksonville State: Fl Zip: MS39202Phone (Other): +1-904-555-0123

Section III: Informants

Name: JacksonRichards Relationshipto the client:Brother

Name:VivianRichards Relationshipto the client:Mother

Section IV – Presenting problem (Reason for referral – Chiefcomplaint)

Theprimary reason that the patient was brought in for evaluation is thathe had made a suicide attempt by overdosing on prescription drugs.Fred seems emotionally broken. Minor issues irritate the patient, andgirls do not fascinate him like other adolescent boys of his age. Itis noteworthy that he quarrels with his father every time he visitsthem. The constant anger has decreased his capacity to eat properly,make new friends, associate with his father and perform well atschool. It was also reported that he does engage in self-harmingactions such as putting incisions on his body.

Section V – History of Presenting Problem Including (onset,precipitators, environmental contributors, severity) and Placement Hx

Fred lives with his mother who asserts that he is irritable and doesnot like the company of the boys of his age. Moreover, heloved his father with a passion, and so hesuffered the biggest heartbreak after his parents broke up. Heassociates his persistent sadness to the shatteredemotional attachment with his dad, and this can be proven bythe extreme anger he portrays each time heis due for the biweekly visits.

Bio psychosocial – Sept5, 2016Fred Richards Page2 of 4

Section VI-Developmental/Physical &amp Family History (Pregnancy/Birth including fetal exposure to drugs/ alcohol/ tobacco. Milestones-including visual, hearing, or other medical issues, parental/Marital HX, drug allergies).

Althoughthe patient was not exposed to either drugs or alcohol, the motherdescribed him as being irritable most of the times. Besides, thepatient often quarrels with his father whenever he visits him, and heexplained that this is why he is often sad since he no longer feelsemotionally attached to him.

Developmentalmilestones: None

Visual, hearing, or othermedical issues: None

Drugallergies: None

Section VII-Education History (Schools Attended, Behavior, Academic Performance, Special Needs/ Services

Beforejoining Englewood High School, the client used to attend the AtlanticCoast High School, and he always used to perform well. He is in theeleventh grade, and he has never held back a grade. However, since hetransferred to the current institution, his behavior, as well asgrades, started deteriorating. The client’s school does not haveany special services.

Section VIII Past Treatment-RECIPIENT (Where, What, When Medication level of Participation/Effectiveness)

Itwould also be necessary for the clinician to consider theperpetuating factors that make the depression continue. Although thepatient was not treated for his condition, his family doctor hadprescribed some medication with the hope that it could eliminate thepresenting symptoms. The client commenced the treatment three monthsago, but the drugs did not help with the severity of the condition,and the mood disorder symptoms such as appetite changes and agitationkept on recurring.

Section IX Past Treatment-FAMILY (Where, What, When Medication level of Participation/Effectiveness)

Whenthe client’s mother was irritable following the divorce with herhusband, she responded positively to the medication. The identifiedfamily member could have had a different mood disorder, but herpositive response to treatment indicates that the sick person’sgenetics are resilient, and he can also recover. The ailingindividual does not have a medical comorbidity, and this eliminatesthe possibility of any prescribed medications interfering with hiscondition.

Section X – Cultural? Spiritual (Beliefs, Practices, Rituals)

Theclient comes from a Christian family. Although Fred’s family usedto go to church together, they no longer do so since the divorce, buthis mother occasionally attends weekly services. Moreover, the clientnotes that his family does not have any special beliefs andpractices.

Section XI – Multi dimensional Functioning (Cognitive, Social, Emotional, Functioning/Norms/ Influences)

Theemotional development of the patient at this stage should reflect thekind of relationships that they form and the role it plays in theconflicts that might occur in their lives. The fact that thepatient’s parents divorced just recently indicates that Fred couldhave developed depressive feelings due to the strained relationshipwith his father since he no longer lives with them. Fred reports thathe had developed an emotional attachment to his father before hisparents separated, but he no longer communicates with him.

Section XII – Current Environmental conditions/ Stressors (Circumstances contributing to symptom severity Parent or guardian willingness to participate in Tx)

Someof the aspects that influence an individual’s behavior and that canbe linked to the patient’s diagnosis include their peerrelationships, neighborhood, school, and family. These factorscomprise the individual’s environment and the role it plays intheir mental health and risk-taking behavior. Parents significantlyinfluence the behavior of the adolescents in the family, and thisexplains the importance of the close relationships between teenagersand their parents. Since the patient’s parents separated, he lacksthe father-figure modeling from his absent father. This aspect couldhave contributed to his involvement in the risky behaviors.

Bio Psychosocial- Date :

Page 3 of 4

Section XIII- Mental Status Exam
Stated Age Child Appears:

Younger

Older

Stated Age

N/A

Physical Condition:

Average

Petit

Stocky

Failure to Thrive

N/A

Movement-Coordination

No Difficulty

Awkward

Clumsy

Dev. Delayed

N/A

Grooming and Dress

Neat/ Clean

Adequate &amp appropriate

Nurtured

N/A

Sloppy/ Dirty

Inadequate/ Inappropriate

Neglected

N/A

Eye Contact:

Normal

Brief

Avoided

N/A

Interpersonal:

Friendly

Polite

Cooperative

Engaging

N/A

Withdrawn

Shy/ Quiet

Guarded

Resistant

N/A

Apathetic

Irritable

Uncooperative

Defensive

N/A

Speech:

Articulate

Clear

Logical

N/A

Soft Spoken

Mumbled

Unclear

N/A

Excessive

Pressured

Illogical

N/A

Conversation:

Willing to Engage

Relevant

Related /On topic

N/A

Unwilling

Irrelevant

Unrelated/ Off topic

N/A

English is not the primary language, client speaks:

Alert, Oriented, Recall:

No Impairment

Alert

Oriented x 3

N/A

Some reluctance

Inattentive

Distracted

N/A

Resisted/ Avoided Certain Topics

Unable or Unwilling to recall requested information

N/A

Thought processes:

Coherent

Organized

Logical

Goal Directed

N/A

Lose Associations

Disorganized

Obsessive

Suspicious

N/A

Hallucinations

Delusions

Suicidal

Homicidal

N/A

Judgment and Insight:

Good – Able to anticipate outcomes and use feedback to learn from mistakes

Fair- Able to learn from some experiences

Poor- Difficulty predicting results of choices, does not seem to learn from mistakes

Intellectual Ability:

Below Average

Average

Above Average

N/A

Calm/ reserved

Untroubled

Happy

Elevated

N/A

Subdued

Apathetic

Disinterested

Flat

N/A

Vacillating/ Labile

Tense

Nervous

Anxious

N/A

Sad/ Depressed

Fragile

Angry

Irritated/ Agitated

N/A

Biopsychosocial – PAGE 4 of 4

SectionXIV – Clinical Impressions – Overallsummary of clients to include strengths/weaknesses, barriers totreatment, family dynamics, etc…)

Overallsummary of client to include strengths/weaknesses,barriersto treatment, family dynamic, etc. NOT TO BE COPIED FROM BRIEF

Someof the client’s strengths include his lack of a medicalcomorbidity, which eliminates the possibility of any prescribedmedications interfering with his condition. Besides, his mother iswilling to participate in his treatment. His weaknesses include theloss of concentration and the lack of interest in maintainingrelationships. The client’s barriers to treatment include his useof drugs and the lack of the father-figure modeling from his absentfather.

Section XV-Diagnosis (DSMIVR, DSM-IV TR, ICD-CM, or DC: 03
Axis

5 Digit Code

Description

I

The suicide attempt that the patient made illustrates that he has a psychiatric disorder that requires treatment

II

V71.09

Depressive symptoms might have been present for a long time, the appropriate treatment would still help the patient recover from the disorder

III

IV

V

Current GAF:

Highest GAF in past 12 Months:

Has diagnosis internally/externally changed? If so, explain why Yes No Unknown

Past current R/O diagnosis? How will it be? Was it ruled out? Yes No Unknown

Explanation:

The clinician should utilize screening tools for misery to evaluate suicidal ideation, but one should still inquire about the patient symptoms to ensure the accuracy of the results. A treatment plan is necessary for the patient to recover from depression and to reduce the risk of self-harm in the future. The clinician should also find out the availability of protective factors that would act as social support for the patient once the treatment commences.

Yes NNo Diagnosis by a licensed practitioner?

Evaluation: Mental analysis

Assessor name/ Cred: Dr. Patrick

Evaluation type: BRIEF EXAM

Yes No Provisional diagnosis by unlicensed counselor – Licensed Review Required?

Reviewer Signature: J.K Signature Sept 5, 2016.

Print Reviewer James Patrick Title/Position: Pediatric Psychologist

Section XVI – Service Recommendations (Who, What Problem, What Intervention, When to Discharge)

DO NOTDUPLICATE THE RECOMMENDENDATIONS OF THE ASSESSOR. Developrecommendations for the clients treatment that you plan to work on ,who you plan to work with, what interventions you plan to use, andwhen it will be appropriate to discharge.

Consideringthat the patient had once tried medication with the hope ofalleviating his symptoms, but it failed to work, it might still takelong to find the best treatment for him. However, his mother’spositive response to her treatment for irritability is a protectivecharacteristic in the biological domain. After the cliniciandetermines the patient’s level of depression, developmental level,and risk factors, he or she would settle on psychotherapy orpharmacotherapy as the treatment options.

Cognitivebehavior remedy is a therapeutic form that can be effective intreating depression for an adolescent. Since the clinician alreadyhas an idea of some of the social issues that the patient has, theycan use a combination of behavioral activation techniques toeliminate the depressive symptoms. The clinician can also applyinterpersonal therapy techniques to regulate the patient’semotions, improve his peer relationships, and help him solveproblems. The physician can also implement pharmacotherapy with theappropriate antidepressant medication. The practitioner can dischargethe client in 12 weeks after administering the interventions.

Name/ Couselor: JamesPatrick Date of signature: Sept 5, 2016.

Title/position: Counselor NPI #: 1245319599

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