Therapeutic Intervention Project
The first section of your paper will present your client’s background. Who is the client? Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, cultural background, socioeconomic status, sexual orientation, religion, occupation/grade level, marital/family status, education goals and coping skills and weaknesses.
Family history– Past and present. Include marital status of parents and any dates of family structure changes or deaths. Include a description of relationships with family members, living arrangements, parents’ occupations. Include statement affirming/denying substance abuse, physical abuse, or sexual abuse among family members, if appropriate.
Social relationship history– Past and present. Include a statement affirming/denying any unwanted sexual experience, physical abuse, trouble with the police. How are relationships with friends, peers, coworkers, teachers? How were they before the onset?
Academic/work history– Past and present. What was/is school like? Academic aspirations? How was experience and performance before the onset?
Medical history– Past and present medical conditions, hospitalizations, prescription medicines, problems with eating, sleeping, weight control, alcohol, and substance abuse. When was the last physical?
Counseling history– For what issue(s)? Was this voluntary or involuntary? List provider names, dates of service. Include self-help groups like AA – incorporate a summary of experiences.
Description of the Presenting Problem
In the next section of your case study, you will describe the problem or symptoms that the client presented with.
Describe any physical, emotional or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported. Estimated date of onset, concurrent events, intensity, frequency, changes in symptoms. How long has this been going on? How often? Magnitude?
Diagnosis (DSM-V)
Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the clients symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.
Describe the observations that support each diagnosis if there are multiple. Be sure to cite evidence from your on-line research and from your textbook. Give rationale by using the facts to justify your definitions of the problem.
