Treatment Plan Based on Biopsychosocial Needs

please see attachment. 

Imagine you work as a human services practitioner at a state prison and have been assigned to manage Casey Hamburger as she starts to plan for her upcoming re-entry into society in 3 months. She has spent the past 15 months incarcerated. Read her

biopsychosocial evaluation

. She will need support in addressing her lack of resources, a home to go to, and any daily skills before leaving prison.

Write a 850-word report on strategies for how to manage your client’s biopsychosocial needs and needs related to re-entry. Complete the following in your report:

· Identify your client’s needs based on the biopsychosocial evaluation (take into account your client’s needs related to re-entry, including lack of resources, a home, and limitations in daily skills.).

· Discuss short-term and long-term goals.

· Describe strategies for managing your client to help achieve these goals.

· Discuss the desired outcome after 3 months.

CPSS/300 v3

Biopsychosocial Evaluation

CPSS/300 v3

Page 2 of 2

Biopsychosocial Assessment

Date of Service: 5/1/2021

Client Name	Client Number	Referring Agency
Casey Hamburger	001	Carter Correctional

Client Information and Demographic Information

☐ Male ☒ Female

Age: 32

Date of Birth: 05/19/1989

Address:

1619 Grass Court Fort Walton, FL 32945

Telephone Number: 555-555-3213

Race: White not Hispanic

Living Situation and History

Current Living Situation:
(Include individuals living within the house)

Client is currently incarcerated at Airy Institute. Prior to being incarcerated, the client reports that she was homeless and had been staying with different people since last partner passed away. Client reported staying with her half-brother’s father at times. Client reported “couch surfing” sometimes.

Family and Marital History:

(Include childhood history; family of origin; location of parents, siblings and children; current living situation; client’s support network; family history of mental health care, alcohol or substance abuse)

Client reports her parents are both from St. Lucie County. Client reports that she has 2 siblings from her biological parents. Client reports that she did not grow up with her biological siblings. Client reports that her older brother Allen grew up with their father and her older sister Alice grew up with her mother. Client was taken in by her biological maternal grandmother, Ginger Jones, and grandmother’s husband, Alex Jones around the age of 6. Client’s mother had custody of client and gave her to the grandparents to care for client. Client has a younger half-brother who shares the same mother. Client’s parents were not involved in her life as a child and currently. Client reports there is no mental health history in the family besides her maternal grandmother who has depression. Client reports that her father uses crack and drinks alcohol often. Client does not report any substance use from any other members.

Client has 4 children. Michelle is 8 y/o female who stays with her father. Ike is 4y/o male that lives with the client’s father’s sister and her husband. India is 2 y/o female and Sky is a 7 month female that both reside with the biological father’s sister. India and Sky father recently passed away from suicide. Client is not married.

Client reports that she does not have any support anymore from family or friends.

Abuse History:
(Include history of past or current emotional, physical or sexual abuse.)

Client reports being raped around the age of 6-7 y/o. Client reports emotional abuse from Michelle’s father while they were together.

Education:
(Include highest grade completed, special classes, current grades and functioning in school)

Completed 11th grade from Walton High School. General Ed classes. Client attempted to complete Adult Ed but never finished.

Employment and/or Military History:

No military history. Began working at age 16 to present in multiple fast food chains. Was not working prior to incarceration due to lay off.

Legal History:
(Include who has custody or guardianship (if applicable), history of arrests, pending charges/court hearings and probation)

Client’s daughter Michelle, client has full custody off but Michelle lives with the father. Client’s son Ike, client does not have custody of. Client’s daughters India and Sky, client has open case regarding custody arrangement of with DCF.

Client had a DUI in 2019 and spent about 4 months in jail.

Client has been arrested for driving without license, currently open case.

Client currently incarcerated for possession of substance and is serving 18 months.

Client’s Input About Possible Solutions and Stated Goals For Treatment:

Client is open for counseling and sees that talking about recent loss could be beneficial. Client would like to get her children back as she states that is all she has.

Medical History

Allergies to food or drugs:

None reported

Childhood Diseases:

Seizures since the age of three. Unknown what prompts seizures they are intermittent when they occur.

Language Functioning (please indicate):

Speech: Normal If Other explain:

Hearing: Normal If Other explain:

Visual Functioning
Normal If Other explain:

History of:

Seizures ☐ No ☒ Yes If yes explain: Since the age of 3, unknown to reason why they occur.

Diabetes ☒ No ☐ Yes If yes explain:

Hypertension ☒ No ☐ Yes If yes explain:

Cancer ☒ No ☐ Yes If yes explain:

Hepatitis ☒ No ☐ Yes If yes explain:

Heart disease ☒ No ☐ Yes If yes explain:

Head trauma ☒ No ☐ Yes If yes explain:

Smoking ☐ No ☒ Yes If yes how much: Half a pack a day of cigarettes

Alcohol ☒ No ☐ Yes If yes how much:

Caffeine ☐ No ☒ Yes If yes how much: 10 cups a day

Surgeries:
(Please list)

None reported

Current physician(s):

Does not have. Did see Dr. Tobias for all her pregnancies

Current medications:
(Please list)

Inhaler for asthma

Additional Comments:
(As related to major health problems, last complete physical examination or family history of chronic medical/psychiatric illnesses, indicate if immunizations are up to date)

Last physical exam in December 2018. Client does not have any medical insurance at this time. Client reports getting yearly flu shot and immunizations are up to date.

Psychiatric History:
(Include prior treatment, Baker Act admissions, hospitalizations, diagnoses, and client’s response to all previous treatment episodes, etc.)

No previous Baker Acts or hospitalizations for psychiatric needs. Client states she has Depression, Bipolar, and ADHD. Client reports being diagnosed with Depression in 2010 and tried medication but reports it never worked for her. Client reports being diagnosed with Bipolar in 2015. Client reports ADHD diagnosis around the age of 10-13 which she was taking Adderall for but stopped taking around the age of 18 due to lapse in medical insurance. Client is not taking any medications currently.

Client reports being in counseling in 2015 after birth of Ike but cannot remember much about treatment.

Substance Abuse History:
(Include age first used, indicate past or current use, amount and frequency and Consequences of use related to school, work, family)

Client reports using marijuana around the age of 13 y/o and stopped around age of 20 y/o. Client smoked daily. No consequences on school, work, or family.

Client reported drinking excessively in 2015. Client reports drinking anywhere from 1 L of liquor or beer a day if not more. Client was arrested for DUI in October 2015 and went to jail. Client reports has not drank alcohol since being released from jail in 2015.

Client reports using pain pills, noting Lortab as specific kind. Client reports taking Xanax at times to help with sleeping. Unknown how often or frequently. Client reports no use currently.

Was ASAM Assessment Completed?

☐ Yes ☒ No

Has the Drinking/Drug Pattern Changed?

☒ Yes ☐ No How? Client reports not using substances as she previously has before.

Has the Client Ever Tried to Control Drinking/Drug Use?

☒ Yes ☐ No How? Client quit drinking alcohol after DUI and jail time. Client reports she stopped smoking marijuana. Client reports intermittent use of pain pills throughout her past.

Does Client Believe His/Her Use of Alcohol or Drugs Caused Any Problems?

☒ Yes ☐ No How? Legal issues and DCF cases that have affected her children.

What Is the Longest Period of Sobriety in the Past Two Years?

1 year

Has the client ever had:

☒ blackouts ☐ seizures ☐ hallucinations ☐ delirium tremens (DT’s).

Describe prior substance abuse treatment:
(Please include duration, response to treatment and if any Marchman Act hospitalizations)

Methadone treatment for approximately a year. Client was in treatment during her pregnancy and reports following through on treatment.

Client’s Perception of His/Her Strengths and Abilities:

Reports her children are her strength.

Client’s/Caregiver Perception of His/Her Weaknesses and Needs:

Urges to drink at times and use pills.

Client’s/Caregiver Barriers and Limitations to Treatment:

Medical insurance and current cost for treatments. No driver’s license and ability to drive self.

Mental Health Status and Behavioral Observations

Physical appearance: Appears stated age If Other explain:

Dress and grooming: Well Groomed If Other explain:

Facial expression: Positive Eye Contact If Other explain:

Motor activity: Restless If Other explain:

Behavior: Cooperatative If Other explain:

Oriented to: Person, Place, and Time

Speech: Soft If Other explain:

Affect: Appropriate If Other explain:

Mood: Anxious

Eye Contact: Good

Communication with interviewer: Good

Memory:
(i.e. recall 3 items after 10 minutes) Intact

Audio/visual hallucinations: ☒ No ☐ Yes If yes explain:

Sleep disturbance: ☐ No ☒ Yes If yes explain: Unable to sleep, as mind is constantly going

Delusions: ☒ No ☐ Yes If yes explain:

Appetite changes/weight loss: ☐ No ☒ Yes If yes explain: Lacks appetite due to recent losses of partner in May 2019 and grandfather in December 2018

Change in energy: ☒ No ☐ Yes If yes explain:

Negative attitude/self-blame: ☐ No ☒ Yes If yes explain: Since childhood and recent suicide by partner

Loss of interest in fun/pleasure: ☐ No ☒ Yes If yes explain: loss of partner, loss of job, legal issues

Prior suicide attempts: Denies

Current suicidal thoughts, intent or plan: Denied

Current homicidal thoughts, intent or plan: Denied

Insight into the problem or situation: Client is
aware to her current situation and problems and how those are impacting her life. She seems willing to seek treatment but does show hesitation.

Judgment:
(i.e., good, fair, poor) Fair, client acknowledges her substance and life choices have made an impact on her children and her ability to see her children. Client does not seem to directly see how substance use is impacting all aspects of her life. Client has significant trauma and abonnement issues that appear to not have been addressed.

Intelligence:
(i.e., above average, average, below average) Average

Behavioral Functioning History

Fire Setting: ☐ No ☐ Yes If yes explain:

Animal Cruelty: ☒ No ☐ Yes If yes explain:

Shoplifting/Stealing: ☒ No ☐ Yes If yes explain:

Verbal Aggression: ☐ No ☒ Yes If yes explain: Client reports that she does engage in if someone talks about her or someone says something she does not like

Physical Aggression: ☐ No ☒ Yes If yes explain: With past intimate partners or in school client was suspended/expelled for fighting

Running Away: ☒ No ☐ Yes If yes explain:

Carry/Use Weapons: ☒ No ☐ Yes If yes explain:

Problem with Authority: ☒ No ☐ Yes If yes explain:

Disregards Rights of Others: ☒ No ☐ Yes If yes explain:

Pervasive Lying: ☒ No ☐ Yes If yes explain:

Trauma History: ☐ No ☒ Yes If yes explain: Raped at age 6 or 7

Abandonment History: ☐ No ☒ Yes If yes explain: Biological parents

Other:

For Any Behaviors Above Checked “Yes,” Please Provide History, Intensity, and Frequency:

Verbal aggression started approximately in middle school until current. Client reports only when someone confronts her or she disagrees with someone is when she will act. Client reports it just happens if it needs to.

Physical aggression has begun initially in school where client would be involved in fights and has been suspended and expelled for fighting. Client reports as she has aged she does not fight physically as much. Client reports that she has fought with past intimate partners and intensity was minor.

Client feels abandoned by her biological parents. Client reports her mother and father were never active in her life as a child growing up but her siblings were raised by the parents. Client refers to father as “sperm donor”.

Treatment Recommendations:
(i.e., is client appropriate for treatment? If yes, why?)

Yes. Client reports a long history of drugs and alcohol which lead to the loss of her children. Client reports she has faced the loss of two loved ones within the past 6 months. One was her grandfather passing away. Another loss was the suicide of her partner/father of her last two children within the past month. Client reports that suicide of her partner has been extremely difficulty. Client also recently lost her job within this past month and is currently facing homelessness.

Client would benefit from weekly counseling addressing past trauma, loss, creating coping skills, making positive choices to move forward with completing her case plan. Client to start seeking outside support services after release.

Presenting Problem:

Client to address her issues of family stressors that lead to poor choices and anxiety. Client needs to address her lack of resources, a home to go to, and any daily skills before leaving prison.

Provisional Diagnoses:

ICD-10-CM Code	Diagnosis Notes	DSM-V Criteria
F43.23	Adjustment Disorder with mixed anxiety and Depressed mood	The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor Significant impairment in social, occupational, or other important areas of functioning. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. The symptoms do not represent normal bereavement. Specify: With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant.

Copyright 2021 by University of Phoenix. All rights reserved.

Copyright 2021 by University of Phoenix. All rights reserved.

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