Comprehensive Client Assessment Paper

LEARNING OBJECTIVES

Students will:

Assess clients presenting for psychotherapy
Develop genograms for clients presenting for psychotherapy

To prepare:

Select a client whom you have observed or counseled at your practicum site.
Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.

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The Assignment

Part 1: Comprehensive Client Family Assessment

With this client in mind, address the following in a Comprehensive ClientAssessment (without violating HIPAA regulations):

Demographic information
Presenting problem
History or present illness
Past psychiatric history
Medical history
Substance use history
Developmental history
Family psychiatric history
Psychosocial history
History of abuse/trauma
Review of systems
Physical assessment
Mental status exam
Differential diagnosis
Case formulation
Treatment plan

Part 2: Family Genogram

Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).

Hernandez Family: Episode 6
Hernandez Family: Episode 6
Program Transcript
FEMALE SPEAKER: So last week I showed you how to make a genogram, like
this one. Now, the idea behind making a genogram is to help you draw a picture
of your family history. And then we use that to discuss the relationships and
connections among your relatives. OK? So Juan, why don’t you start off and talk
about what you came up with.
JUAN HERNANDEZ: So we’re starting with my family. My father, Hector, he’s still
alive. And he married my mother, Freda. And she passed away two years ago.
And then there’s their children, myself– I’m the oldest– and then there’s my three
sisters, Marie, Senta, and Rose.
FEMALE SPEAKER: Good. And Elena, what about your family?
ELENA HERNANDEZ: Well, here’s my father, Anthony. He met and married my
mother, Sofia. They are both still alive. They had five children. Firstborn was my
brother Daniel, then my brother Tomas, then my sisters Martina and Camila, and
there’s me, the baby.
And then I met Juan, and we started our own family. And we have two beautiful
sons that you met, one, Junior, who is eight, and Alberto, who is six.
FEMALE SPEAKER: Good. So for the last several weeks we’ve been talking a lot
about how you discipline your sons at home. And both of you mentioned how
your parents used to punish you when you were growing up. Juan, why don’t you
talk about that and point to anybody on the genogram as you mention them?
JUAN HERNANDEZ: Sure. So my dad, when he was mad at me he would send
me to get books from the encyclopedia. And he’d make me hold them out,
straight out like this, until he told me to stop. It caused so much pain in my arms,
I mean, my arms felt like they would break off.
And my mom, she did basically the same thing. Except when she was really
mad, when would make me get more books than my dad. I hated those books so
much. I never went near them on my own. To me, they only meant one thing,
misery. And now, I guess I inherited that from them.
FEMALE SPEAKER: Elena, how about you?
ELENA HERNANDEZ: Yes, misery. That’s what it was like for me, too.
© 2016 Laureate Education, Inc. 1

Hernandez Family: Episode 6
Hernandez Family: Episode 6
Additional Content Attribution
MUSIC:
Music by Clean Cuts
Original Art and Photography Provided By:
Brian Kline and Nico Danks
© 2016 Laureate Education, Inc. 2

Comprehensive Client Assessment Paper