Summarize the client. What is the rationale for seeking counseling?
Description I. Introduction A. Summarize the client. What is the rationale for seeking counseling?
II. Biopsychosocial Summary
A. Describe the problem that brought the client to treatment. i. Make sure to address any problems, issues, or challenges the client may be facing.
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Order Paper NowB. Explain the symptoms affecting the client. i. What are the behavioral symptoms? ii. What are the cognitive symptoms? iii. What are the emotional symptoms? iv. What are the physiological symptoms?
C. Identify any environmental factors that may be contributing to the client’s problem.
D. Identify any potential harmful behavior: i. Aggression ii. Harm to others iii. Harm to self iv. Criminal activity v. Impulsive behaviors vi. High-risk activity
E. Determine if the client has a family history of the diagnosis. Consider how this may affect the client. F. Use evidence-based research to support the biological factors presented in the case.
G. Outline how the client identifies him- or herself in regard to cultural characteristics. Make sure to add rationale for any answers that are not straightforward. i. What are the addressing factors?
a. Age and generational influences
b. Developmental disabilities (acquired at birth or during childhood)
c. Disabilities acquired later in life (e.g., traumatic brain injury, multiple sclerosis, stroke)
d. Religion and spirituality
e. Ethnic and racial identity
f. Socioeconomic status
g. Sexual orientation
h. Indigenous heritage
i. National origin j. Gender
H. Summarize how the client culturally identifies him- or herself.
i. With the identifiers above, how does the client culturally identify him- or herself? ii. What is the order of importance for the client? Assessment III. Co-occurring Disorders
A. Identify any co-occurring disorders. B. Describe the initial DSM diagnosis. i. What is the overall descriptor of the diagnosis? ii. What criteria must be met to meet the diagnosis? iii. Describe which client behaviors are being used to meet the diagnostic criteria.
C. Discuss the rationale behind the diagnosis. i. Identify what other diagnoses should be ruled out. Make sure to provide rationale. ii. Identify limitations with this diagnosis. Make sure to provide rationale.
D. Use evidence-based research to support your justification. IV. Addiction Assessments
A. Describe how the assessment was administered.
B. Describe the assessment scoring.
C. Summarize the assessment results.
i. How do you interpret the results? Plan V. Recommendations
A. Summarize what you recommend for this client based on the information collected.
i. Describe what you recommend for recovery.
ii. Describe what you recommend for relapse prevention.
resources you would provide to the client. Rubric Guidelines for Submission: Consider using the headings from the critical elements outlined above when drafting your DAP note, as you will do this when you submit for your final project. You may also consider using double spacing, 12-point Times New Roman font, and one-inch margins, although none of these specifications are required for the draft version. Critical Elements Pro
Client Name______Anessa________________________________ Chart # NA______________________
Evaluating Counselor ____stephanie Badio_________________________________ Date 12/13/20__________________
Please indicate “NA” if the question/section is not applicable to the client’s history. DO NOT LEAVE ANY SECTION/LINE BLANK.
Presenting Problem: (Include the client’s own words about why the services are needed, any referrals, and major stressors over the past six months.) Client mentioned during a dance competition she dislocated her knee. Client mentioned being prescribed with pills after injury which led to tolerance to pain killers. Client is here to obtain guidance regarding excessive amount of consuming medication. Anessa stated, she went to seek a different doctor after her previous doctor denied her.
Past Treatment History: (Include past treatment history for substance abuse AND mental health services.). Patient mentioned past history of substances when injured knee and depriving herself of food. No past mental history noted.
Family History: (Include biological family members, number of children, divorce, separations; describe what it was like growing up in this family, and include substance abuse and psychiatric history of family members.) Anessa is a middle child, she grew up with both of her parents she was an athlete who was in dance and ballet. She was very successful and won many rewards. Anessa experienced substance abuse but no psychiatric history known at this time. Both of her parents were hardworking and present in her life.
Substance Abuse Drug History: (Include top three drugs of choice.)
1.oxycotin
2.Vicodin
3.NA
| Substance Type | Age of First Use | Route of Administration | Amount Used | Frequency of Use | Date of Last Use | Treatment Where/When |
| Alcohol | NA | NA | NA | NA | NA | NA |
| Cocaine | NA | NA | NA | NA | NA | NA |
| Marijuana | NA | NA | NA | NA | NA | NA |
| Heroin | NA | NA | NA | NA | NA | NA |
| Other Opiates | Senior year | Bi mouth | 10-15pills | Twice daily | still | counseling |
| BZs | NA | NA | NA | NA | NA | NA |
| Methadone | NA | NA | NA | NA | NA | NA |
| Suboxone | NA | NA | NA | NA | NA | NA |
| Tobacco | NA | NA | NA | NA | NA | NA |
List any withdrawal symptoms as reported by client (sweats, constipation, DTs, seizures, etc.):
No known symptoms reported by client at this time.
Social History
Client’s Current Life Situation: (Summarize present living arrangements and any current social supports.)
Client is currently taking 10-15 pills per day and her mother suggested to seek further treatment.
Sexual Orientation: Anessa is a female
Spiritual Beliefs: not disclose NA
Employment History
Employment: (Include longest continuous employment, type of employment, typical length of stay, present employment, and military history.) Client did not mention any employment due to injury client has not been able to work.
Education: (Note highest level of schooling completed, school performance, peer relationships, and learning problems.) client completed high school and some college. Client did not mention any close/stable relationship at this time.
Medical Health History: (Include illnesses, surgeries, medications [OTC and prescription]. Note any current medical problems, physical disabilities, and/or eating disorders. Include gynecological history and pregnancies.) Client mentioned injury in knee due to dance. Client was prescribed both Vicodin and OxyContin for the pain.
Primary Care Physician:
Name: ______________Na___________________________________________
Address: __________NA_____________________________________________
Phone: __________NA____________________ Fax: _NA______________________
Date of Last Physical Exam: _________NA___________________________
Hospital of Choice: ________NA___________________________________
Allergies: ___________no known allergies___________________________________________
Medical Medications: (Include name of medication, dose, condition it is treating, and its effectiveness.)
_______________oxycotin______________________ ______________vicodin_____________________
_____________________________________ ___________________________________
_____________________________________ ___________________________________
Mental Health/Psychiatric History:
Have you ever been treated for a psychiatric illness: Yes or No
Please explain: (Include if client has been hospitalized, seen by a mental health professional, what they were seen for, and how long they were seen.)client denied being seen for any psych issues
Any SI/HI or plan in past or present? (Please explain if “yes”) Patient denied any SI and HI
Psychiatric Medication History:
| Drug Name | Prescriber | Dosage | How long have you been taking it? | Are you currently taking this medication? | Reason for this medication/diagnosis |
| OxyContin | NA | NA | Since highschool | yes | injury |
| Vicodin | NA | NA | Beginning of college | yes | injury |
Legal History: (Note any charges and dates, any outstanding warrants, court dates, description of crimes, convictions, incarcerations, etc.) NA
· No legal issues
· Currently on probation
· Pending warrants
· Jail term served
· Court cases pending
· Parole
Explain with detail any and all of the above checked:
Clients Self-Assessment of Strengths:
1. _______dancer_______________________positive
2. _______active_______________________
3. ______________________________
Clients Self-Assessment of Weaknesses
1. _________tolerance
2. ability to stop_______using______________
3. ________unengaged ______________________
4. ______________________________
5.
Recommendations: (This narrative section pulls all of the information together, with a clinical opinion about what the primary issues are and what should be done to address them. Also state potential referrals to rehabilitative, IOP, and so on that are appropriate at this time.)
Clinician/Counselor Signature: _________stephanie B___________________________ Date: ___________
Clinical Director Signature: _______________________________________ Date: ___________
