Write a comprehensive 7 pages biopsychosocial assessment based upon the “Psychosocial/Diagnostic Evaluation Session” of the Maggie Perez vignette, focusing on the ecosystem and strengths perspective of the client. Include information under the following headings:
Narrative of presenting problem
Current stressors and reason for referral
Mental status (orientation, mood, affect, speech/language, thought content, psychotic intrusion, judgment, intellectual capability, insight, and motivation for treatment)
Social activities and skills
Risk assessment (Suicide/homicide/violence/victimization)
Family history and culture (relevant to understanding the client’s strengths and needs)
Medical and mental health history
Substance abuse history
Trauma history (abuse/loss/traumatic events)
Educational/vocational/military history
Legal history
Concrete needs assessment
Strengths and resources
Barriers to treatment
Treatment goals
Diagnostic impression and treatment recommendations
The problem statement should always include the client’s diagnosis and key presenting symptoms, and must be written in a single sentence, as follows: “(Client’s name) is diagnosed with XYZ disorder, as evidenced by…” Then list the symptoms s/he has identified which are consistent with the criteria of the DSM diagnosis you’ve selected. For example:
(Client’s name) is diagnosed with anorexia nervosa, as evidenced by restricted eating pattern resulting in 30% loss of original body weight; intense fear of weight gain, and denial about her underweight condition.
Sample Solution