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Treatment plan

Description

only Goals, objectives, and interventions… 

Roberta was a 69-year-old, never-married woman who sought treatment. She reported ¥ing in a funk all the time,®bsp;having trouble sleeping, and being overwhelmed by the demands of caring for her 62-year-old brother, Jonathan, who had long been disabled by bipolar disorder. Robertaænbsp;mother, Edna, had been Jonathanænbsp;caregiver his whole life, but when she died one year ago after a long battle with Parkinsonænbsp;disease, his care fell primarily to Roberta and secondarily to her sister, Geraldine, who lives further away from Jonathan than Roberta and has children of her own for whom she is primary caregiver. Because Roberta has never been married and has no children, the family assumed she would take over Jonathanænbsp;care, but this was never discussed. Roberta had been employed for many years as a clerk in a local bookstore, but she was severely injured by an uninsured driver in a car accident 13 years ago and was forced to retire early on disability. As a result, Roberta has very limited financial resources.

Roberta resides in a one-bedroom apartment and has just received notice that her rent is being increased. She lives in an expensive community and, while the rent used to be affordable, the complex changed owners five years ago and her rent, which had been stable for 20 years, has been increased incrementally every year over the past five years to the point that she now feels she cannot afford to remain there and ¥els overwhelmed®bsp;by the thought of leaving her home and community of more than 25 years.

Jonathan recently moved into Robertaænbsp;apartment and is sleeping on her couch. The move was necessitated by the need to get their motherænbsp;home ready to sell. The home needs a significant amount of work, but their mother owned it outright, and it is in a desirable neighborhood. The proceeds will be split between the three kids, which will help, but there is concern that Johnny will lose all of the medical and disability benefits, which he is used to and on which he depends, if he suddenly inherits some money from the sale of his motherænbsp;house.

Roberta states that, å don really get along.®bsp;She sees her brother as very rigid in both his personality and expectations. Their mother )d everything for him,®bsp;according to Roberta, and she feels that he expects Roberta to do the same. Roberta states, fnbsp;know Johnny has problems, but he has never worked and never lifted a finger. Itænbsp;no wonder things never get better for him.®bsp;In the past month, Roberta and Jonathan have argued frequently about verything,®bsp;and Roberta tearfully states, Rm not sure how much longer I can take all this.®bsp;Jonathan is relatively healthy but is easily distracted and /esn do anything for himself®bsp;according to Roberta. % didn clean up after himself, cook, or do anything when he lived with mom, and now he thinks Ifnbsp;just going to take over,®bsp;Roberta states through gritted teeth. Roberta reports that her brotherænbsp;care was µst sort of thrust upon me®bsp;and that there is no short-term or long-term plan for his ongoing care needs beyond sleeping on her couch until her motherænbsp;house sells.

Roberta has several strengths and resources that have helped her through this difficult time since the loss of her mother. She is on the Board of Directors of the City Library where she lives, and she finds great pleasure in still being involved in (e world of books,®bsp;as she calls it. She has recovered significantly from her car accident of 13 years ago and is able to walk and take care of herself independently, but she now gets periodic migraine headaches, which she says, /tally derail my whole day. I have to take medication that basically knocks me out, and I have to stay in the dark for many hours until the headache passes.®bsp;She didn get these headaches prior to the car accident, but since then gets them as frequently as twice a week, but usually once per week on average. The headaches prevented her from getting a job, as did the long road of recovery from her other injuries, which required years of physical therapy and three surgeries. Even so, Roberta feels optimistic about her recovery from the accident and often talks about /w far I¥ come.®bsp;She says, fnbsp;can live with the migraines because they aren every day. I can still have a life./p>

Furthermore, Roberta has lived and been involved in her community for almost three decades, so she has several close friends and many acquaintances, from the Library Board, for example, who have been a good source of support for her since her motherænbsp;death. She used to go out to eat with friends a couple times per week, but with her increased rent she has felt the need to cut back on that. She has further limited her time with friends over the past month since her brother moved in, because % makes me feel guilty when I leave him to go out, but heænbsp;rude to my friends when they come over.®bsp;For example, she was a part of a regular bridge circle for which hosting rotated, but she was so embarrassed when she hosted this week, and her brother interrupted their game with this long rant about öersexualized old ladies causing trouble®bsp;that she ended the game early and didn attend the next meeting. So overall, Roberta reports that her social support has been significantly reduced because of finances and her brother. Roberta says, !tely, I feel so alone, even though Johnny is here all the time.®bsp;

Roberta stated that she thinks about dying, ostly because I miss mom so much,®bsp;but she denies suicidal ideation or intent. However, she did emphasize that fnbsp;can continue to live like thisïmething has got to change./p>

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Case Study
Engagement, Assessment, Intervention, Termination and Evaluation
This assignment will examine clinical strategies utilized in advanced social work practice with individuals
and/or families. Your instructor will provide a case study. This is a professional paper; it should be at least
15-20 pages in length (not including the cover page or references), typewritten, one and a half spacing and in
APA style of writing. The Biopsychosocial Assessment is one form of specialized assessment. The Mental
Status Exam is another assessment tool. Other specialized assessment tools will have to be researched. Use
of more than one assessment tool is common to reach a diagnosis or to adequately assess clients needing
help.
Outline
Introduction of the Case
Engagement
1) Discuss specialized engagement skills with this particular client.
Assessment
2) Specialized assessments including a biopsychosocial-spiritual assessment (include it in the appendix),
mental status exam, specific assessment tools utilized to help identify and define the problem/s, a
description of the clientàinterpersonal behavior and emotional processes, that either support or discredit
your assumptions, discussion of cultural influences and DSM 5-TR diagnosis with qualifying examples.
Also, include any other screening/assessment tools to evaluate the problem.
Intervention
1) Specialized intervention strategies, techniques and modalities including a behavior/treatment plan (with
goals and objectives that are measurable and observable), cultural and human diversity issues impacting
treatment.
Termination
1) Identify indicators that treatment is in the termination stage and specific strategies how to terminate
treatment with this particular client. Include issues related to closure, celebration, follow-up plans,
processing feelings and referrals for this particular client.
Evaluation
1) Strategies and at least one instrument to evaluate the treatment program (beginning, middle, and ending).
The evaluation must identify how assessments are used to determine evaluation and goal attainment.
Conclusions about the Case and the process
Biopsychosocial Assessment
Demographic data
DATE:
CLIENT NAME:
DOB:
AGE:
GENDER:
ADDRESS:
PHONE (HOME/CELL/WORK):
START TIME:
DURATION:
Primary method of communication:
Referral source:
Funding source:
Completed assessment with:
Current symptoms
Cognitive functions:
Dangerous behaviors & immediate threat to personal safety:
Indicators of personality disorder:
Emotional/psychiatric history
Prior outpatient treatment:
Prior inpatient treatment:
Prior residential treatment:
Date of most recent psychiatric assessment:
Current psychotropic medication:
Prior psychotropic medication:
Family members4reatment history
Has any family member had outpatient treatment?
Has any family member had inpatient treatment?
Has any family member used psychotropic medications?
Family history
Family of origin
Present during childhood:
Parents#urrent marital status:
Describe childhood family experience:
Emancipation from home:
Special circumstances in childhood:
Current family
Marital status:
Intimate relationship:
Relationship satisfaction:
List all persons currently living in clientàhousehold:
List all children not living in clientàhousehold including frequency of visitation:
Describe any past or current significant issues in intimate or immediate family relationships:
Client abuse & trauma history
Description of abuse etc.:
Concerns/needs/issues/services accessed/linkages needed:
Description of trauma:
Concerns/needs/issues/services accessed/linkages needed:
Medical history
Current medical problem(s):
Significant medical history:
List all non-psychotropic medication currently taken:
Nutritional development:
Concerns/needs/issues/services accessed/linkages needed:
Substance use history
Substance abuse history
Family substance abuse history
Concerns/needs/issues/services accessed/linkages needed:
Developmental history
Physical development:
Chronological age:
Prenatal history:
Birth:
Delayed developmental milestones:
Sensorimotor functioning & motor development:
Concerns/needs/issues/services accessed/linkages needed:
Educational development
Last/current grade completed, and school attended:
Elementary, middle/high and college/vocational training schools:
If received special education services:
Concerns/needs/issues/services accessed/linkages needed:
Developmental history (child and adolescent client)
Emotional development:
Mood:
Emotional/behavior problems:
Concerns/needs/issues/services accessed/linkages needed:
Cognitive development:
Cognitive problems:
Concerns/needs/issues/services accessed/linkages needed:
Social development:
Social problems:
Concerns/needs/issues/services accessed/linkages needed:
Socio-economy history
Current living situation:
Daily living skills:
Social support system:
Sexual history:
Military history:
Type of discharge:
Employment:
Financial situation:
Concerns/needs/issues/services accessed/linkages needed:
Legal history/status:
Cultural/spiritual/recreational status:
Spiritual/religious affiliation:
Cultural/ethnicity affiliation:
Community involvement/recreational status:
Guardianship status:
Mental status examination
Appearance:
Manner:
Attitude:
Consciousness:
Affect:
Prevailing mood:
Thought processes:
Content:
Associations:
Speech:
Faculty orientation:
Attention span/concentration:
Perception:
Intellectual functions:
Memory deficits:
Judgment:
Insight:
Additional comments:
Client strengths and weaknesses
Clientàstrengths:
Clientàweaknesses and obstacles:
Client treatment goals and barriers
Client preferences:
Barriers to achieving client preferences:
Duration:
Additional info:
Summary of presenting problems and recommendations
Summary of presenting problem:
Current and past level of functioning:
Clinical impression:
Justification for issues not addressed in treatment:
Conclusions and recommendations:
(Sample) Treatment Planning Template
Treatment plans are an important part of the helping process. Depending on the type of service and the specific
standards and practices of the setting, treatment plans may vary in content. Treatment plans are used to guide
how services will be delivered. Failure to plan treatment places the worker at risk for fraud, waste, and abuse
and could potentially harm the client. Treatment plans provide documentation that services are rendered.
Client Name: Click or tap here to enter text.
SW Name: Click or tap here to enter text.
Date
Problem Statement (Brief clinical statement of the condition that needs treatment.
Based on assessment data.)
Click or tap to
enter a date.
Click or tap to
enter a date.
Click or tap to
enter a date.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Goals
(1) Click or tap here to enter text.
(2) Click or tap here to enter text.
(3) Click or tap here to enter text.
Discharge
Objectives (What will the client say or do? Under what circumstances? How often will
Criteria
the client say or do this?)
Click or tap here to
enter text.
Click or tap here to
enter text.
Click or tap here to
enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Interventions
Target Date
Date Achieved
Click or tap to
enter a date.
Click or tap to
enter a date.
Click or tap to
enter a date.
Click or tap to
enter a date.
Click or tap to
enter a date.
Click or tap to
enter a date.
(What will the SW do to assist the client? Under what circumstances?)
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Client participation in the treatment planning process
Click or tap here to enter text.
Click or tap here to enter text.
Participation by others in the treatment planning process
Click or tap here to enter text.
Click or tap here to enter text.
Client Signature & Date
SW Signature & Date

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