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Treatment Plan Case Study

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Treatment Plan of Ms. Smith
Micah Sparks
Grand Canyon University

Treatment Plan
Case History for Treatment Plan
Psychological Evaluation
Name: Sally Smith
SS#: 000-00-0000
DOB/Age: 6/10/1972 42-years-old
Date of Examination: 11/26/2016
Examiners: Fred Looney, PhD

Chief Complaint: Mental

Sources of Information:

Clinical Interview with Sally Smith
Medical Records
Brief Mental Status Examination
Wechsler Adult Intelligence Scale-IV (WAIS-IV)

Background Information:

Ms. Smith is a 42-year-old African American female born November 10, 1972. She currently lives in with her mother. She states she has one adult son from a prior marriage. Ms. Smith states she has a 2-year nursing degree from and was employed as a nurse until 2012. …show more content…

Refer to be determine by medical doctor if patient has an underlying illness or condition. Intervention 3: complete pain management and substance abuse agreement Objective 3: discuss with primary care physician cautious use of medications (Perkinson, Arthur, & Bruce, 2014)

Problem 3: Major depressive disorder
Goal 3: refrain from any type of self-harm to self or others Objective 1: develop a no harm to self or others contract for client to sign, and to obey while in treatment (Perkinson, Arthur, & Bruce, 2014) Intervention 1: request client to sign a no harm contract. Ask client to call staff members or family if feeling of self-harm should occur. Objective 2: refer for medical evaluation Intervention 2: refer patient to be examined by physician and psychiatrist for full workup of mental stability, and medical conditions. Objective 3: cooperate with biopsychosocial examination (Perkinson, Arthur, & Bruce, 2014) Objective 3: complete biopsychosocial of all family history, assess for any past history of violence or substance abuse, childhood.

Problem 4: failure to comply with medical …show more content…

Sally Smith presented to the office on November 26, 2016 for a psychological evaluation. Ms. Smith appeared casually dress for the occasion, with an apathetic attitude. Ms. Smith denies any use of alcohol prior to the visit, however a slight smell of alcohol was noted during the visit. Ms. Smith was slightly lethargic and had to be redirected to stay on task during the interview. Ms. Smith denies any use of substance, although Ms. Smith’s results of the WAIS-IV scale score indicates an (extremely low) verbal comprehension with a rating of 67, perceptual reasoning score is 73 (borderline), working memory 73 (borderline), processing speed 100 average, full scale 67 (extremely low), with a general ability of 99 average. After the evaluation was completed, Ms. Smith result indicates that she has a strong history of alcohol abuse, along with using opioid medications with alcohol (Weshsler Adult Intelligent

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