Biopsychosocial case history

This assignment requires you to write a thorough biopsychosocial case history of a client with whom you have worked.
Case History (4 pages)
General Instructions: The case history summarizes important backgroundinformation used for evaluating a client for treatment. Be succinct indescribing the case history. Use thebold headings in your report!
Select one of your current or past clinical cases forthis assignment. (If you do not have an appropriate client, please see me.) Provide a fictitious name to protect theconfidentiality of your client. You will use the same name in the twoconceptualization & treatment planning take-home assignments.
Identifying InformationDescribe the client’s relevantdemographics, such as age, relationship status, children, present occupationalstatus, along with a description of appearance, quality of speech, and client’sattitude toward the interviewer.
Presenting Problem & History of the ProblemDescribe the present problem(s), including emotional,cognitive, behavioral, and physiological symptoms. Note environmental stresses.Include a history of the problem and the client’s previous efforts to alleviate the problem.
Past Psychiatric HistoryBriefly summarize past personal and/or family historyof psychiatric or substance-use treatment.
Human Rights& Social JusticeBriefly describe the intersection of the client’spresenting problems with issues of oppression or other violations of humanrights.
Current PsychosocialFunctioningBriefly summarize current functioning related to family/livingarrangements, work/school, financial, medical (including drug use), legal (ifrelevant), or other relevant life situation.
Personal and Social HistoryBriefly summarize personal and social history,including:·Family of origin(parents, siblings, and significant others)·Brief descriptionof childhood, adolescence, early adulthood·Nature ofrelationships with parents, siblings, and significant others·Traumatic eventsduring childhood, adolescence, early adulthood·Educational/workhistory·Medical history –Note any medical problems (e.g., endocrine disturbances, heart disease, cancer,chronic medical illnesses, or chronic pain) that may influence psychologicalfunctioning or the treatment process.·Socialclass/cultural history·Spirituality/religioushistory
Mental Status ObservationsTypically includes adescription of the following: general appearance, level of alertness,quality/style of speech, general behavior, and attitude, orientation (person,time, place), reported mood, observation of affect, thought process, thoughtcontent, short and long term memory, level of insight, judgment, reasoning,and communication style.
Strengths and ProtectiveFactorsInclude a statement about theclient’s strengths and protective factors.
Intersection ofClient/Worker Relationship in Developing the Psychosocial AssessmentDiscuss how issues of power,privilege, and oppression were manifested during the assessment process.Discuss how the client’s identity and demographics intersect with theirproblems. Thinking ahead, how might the client’s identity and demographicsaffect the development of the formulation? What steps may be taken to safeguardthe client’s dignity, self-worth, and human rights?
Diagnostic ImpressionsProvide a general description of symptoms or focus ofthe problem, for example, “The client presents with symptoms of anxiety,especially related to work stressors.”