course material

1. Assignment 1: LASA 2: Assessment and Treatment Plan
As the intake worker at a local community mental health access center, a thorough
assessment needs to be completed for every person that comes in looking for support and
services. Because of the variety of illnesses and treatment options, the more accurate your
assessment and treatment plan the more help you will provide for the client. Choose from
one of the provided case studies to complete the assessment and treatment plan using the
template provided. Directions: Choose a case study.Fill out the assessment and treatment
form. Write a separate summary at the end of the form explaining the best psychological
theory that would best fit understanding this case study. Be sure to include ethical and
cultural considerations. Assignment 1 Grading Criteria Maximum Points Assessment
form.20Description of the disorder and explanation of the symptoms best explain the
behavior of the case study.32Apply assessment information to treatment planning
stage.36Choice and justification of a theory that fits best with this particular
case.32Complete treatment plan form.20Summary of case study.28Analysis of the most
appropriate treatment theory.36Explanation of where ethical and cultural considerations
may arise and what could be done to provide ethical and culturally sensitive
treatment.32Organization: Writing, Ideas, Transitions, and Conclusion16Usage and
Mechanics: Grammar, Spelling, and Sentence structure16APA Elements: Attribution,
Paraphrasing, and Quotations24Style: Audience, and Word Choice8Total: 300 * Case
Studies to choose from Just choose The easiest one an there is a Acessment form that needs
to be completed all are attached.Case Study #1Young-Hwa, a 40-year-old Korean male, had
immigrated to the United States 15 years ago without proper documentation. He had a hard
life because, despite his training as a chef in Korea, he had difficulty finding a well-paying
job without proper documentation. He also had a hard time getting along with others for
long periods of time in some of the kitchens that he worked for. He would do really well for
a while talking about how much he enjoyed the job thinking that this was going to be his
lucky break, but after several months he would either quit or get fired. During these times
of being out of work he is very depressed and irritable and will sleep for days without
coming out of his bedroom. After many years of various positions including kitchen
assistant and assistant cook, he finally landed his dream job of a top chef in a Korean
restaurant.He recently was married to a Caucasian woman who had a daughter from a prior
relationship and now they have twin sons. Their marriage would be described as fairly
good with some hard times. His wife knows his work history and occasionally will
threatened that if he messes this one up, she and the children will be leaving him. However,

2. most of the time she only threatens this when she is angry about not being able to pay a bill,
which causes them to fight. The other main topic of conflict is how he never had time for
her and her daughter, but now spends more time with them with the birth of his sons. He
claims he just has more time and energy now. He also is so excited about the new position,
reassures her that it will not happen this time, and begins to stay up late into the evenings
excitedly planning new menus. Even when he is home, he is busily making new dishes for
her and their neighbors to try.They live in a predominant Koran neighborhood and most of
the couples are kind to his wife and step-daughter, but occasionally question her about
Young-Hwa’s behavior. They mention to her that it is hard to know what you are going to
get when you see him. She dismisses their concerns and explain it away with his stress of
jobs and not having his proper documentation of his training in Korea and hope that his
paperwork that was submitted after their marriage for citizenship will get approved and
that will help his mood.Young-Hwa is the oldest child with having three younger sisters that
still live in Korea near where his elderly parents live. The oldest of the sisters actually lives
with and takes care of his parents. He secretly sends his sister money to help with taking
care of his parents but feels he cannot tell his wife because of her complaints about money
and that she would just not
understand.(Source: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&
part=A68623#A68762Chapter 3 – Clinical Issues Related to Integrating Vocational
Services Case Study #2Julia is a 27-year-old Italian American female. She was referred to a
specialty residential program by the child protective services agency because her daughter
was born with a toxicology screen that tested positive for heroin, cocaine, and marijuana. In
order to keep her baby, she was required to participate in this program with her infant
daughter. Julia was administered a battery of assessment measures during her intake
interview for residential treatment. These measures included the ASI (which measured her
functional status in seven domains) and the Self-Directed Search (which determined her
vocational interests and skills).Julia is an only child. She lives with her mother, a nurse, and
her father, an electrician. Her parents were given temporary custody of her daughter while
she was waiting for placement at the residential program. The clinician learned, however,
that she and her parents have had several physical fights recently, of which the child
protective services agency was not aware.Julia has had 13 years of education. She had been
a nursing major at the local community college 5 years ago but dropped out when she could
no longer manage school due to her polysubstance use. Julia has been drinking to
intoxication on Friday, Saturday, and Sunday since the age of 15. She has also injected
heroin regularly (about three times per week over the last 5 years) and has been smoking
or snorting cocaine on weekends. She often used more than one substance per day–usually
cocaine and alcohol–when she could not get heroin.Julia has been arrested for assault,
breaking and entering, and robbery. However, she was not convicted and has never been
incarcerated. Julia usually got her money for drugs by stealing or by giving sexual favors.
Julia has several close male and female friends who are also using drugs. She has had
serious conflicts over the last 30 days with her parents, sexual partners, and friends. She
reports that her current sexual partner, who sells drugs and is the father of her child, has
physically and emotionally abused her.Julia has been hospitalized twice for suicide

3. attempts. She says that periodically she becomes severely depressed, can’t eat or sleep, cries
a lot, can’t sit still, and has trouble getting out of bed. She is easily irritated when she is
depressed and sometimes has difficulty controlling her anger. Julia also has panic attacks
and is, at times, fearful of crowds, stores, classrooms, and restaurants where she does not
know people. She is also afraid they will see her having a panic attack and think that she is
crazy. Julia has been prescribed imipramine (Tofranil), lithium (Lithonate), and diazepam
(Valium), but none of these medications seem to help. She finds it easier to get herself out of
bed after she has used heroin or cocaine. Julia admits that her drug use may be a form of
self-medication because she “feels better” after she uses.Julia’s ASI composite scores reveal
that she is most in need of treatment in the areas of alcohol and drug use, employment,
social relations, and psychiatric problems. Julia herself rates her need for treatment in the
areas of alcohol and drugs and in psychological functioning as extreme, but she views her
need for employment and social counseling as slight.Julia’s result from the Self-Directed
Search matches her vocational dream of becoming a nurse (like her mother). Julia was
surprised to learn that her summary code was also consistent with dietician,
physical/occupational therapist, and psychiatric technician. She was particularly interested
in the physical and occupational therapy fields because she thought these occupations
would limit her access to drugs and thus eliminate the temptation to steal them, while still
allowing her to work with people in a medical setting.When Julia was approached about
further vocational exploration, she said that the thought of going back to school made her
highly anxious and that she did not think she could ever see herself getting up to go to work
or performing adequately on the job. She felt that she had been using drugs too long and
“hanging out” so long with other users that she did not even know how to talk to “straight
people.” She also felt humiliated about all her arrests and about “doing nothing with her
life” all these years, so she couldn’t imagine filling out an application to go back to school or
interviewing for a job. (Source:
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A68623#A6876
2Chapter 3 – Clinical Issues Related to Integrating Vocational Services) Case Study #3Joe is
a 34-year-old, unmarried, African-American man who lives in a poor neighborhood of a
large city and works as a dock loader for a large trucking company. He returned from war
nine months ago after serving in an 18 month deployment. Joe lives with an aunt and uncle,
paying a small monthly rent for a basement room, after losing his own apartment a couple
months ago. He generally keeps to himself, although he has a few war buddies that he
occasionally hangs out with.Joe never knew his father and was raised by his grandparents.
His alcoholic mother left Joe and two younger brothers in his grandparents’ care when she
ran off with a man—only to die in an accident about a year later when Joe was 8 years old.
His beloved, very religious grandfather died of complications from diabetes when Joe was in
high school. Although his grandmother is alive still, Joe seldom sees her. None of the family
members are close and he hardly know the aunt and uncle he is living with.Now Joe is in
serious trouble: a street brawl that he got into after returning from a bar with friends ended
with the shooting death of one of his friends. Joe is one of those charged, though he swears
he was not involved. He was, however, so drunk that he does not remember what happened.
Because Joe has a history of fighting and a series of previous assault charges, the court has

4. mandated treatment because of the alcohol found in Joe’s urine after his latest arrest.Joe is
overweight but otherwise reports no physical complaints or serious medical problems.The
one bright spot in Joe’s life is the 4-year-old son, Charles, he fathered with a “nice” girl
(Brianna) he has known since high school. Brianna says that she loves Joe and would like
them to be a family. However, she is very concerned about Joe’s erratic behavior and is
thinking about ending the relationship. Although Brianna knows that Joe thinks Charles is
special, she is reluctant to let the father and son go anywhere together—fearing that Joe
might get triggered and go into “anger mode” as she calls it. Brianna is a stabilizing
influence on Joe, with a strong spiritual side that reminds Joe of his grandfather. However,
says he is not the same guy that he was before the war and is sometimes afraid of him when
he “zones out”. Also, Joe knows that his job is in jeopardy if he does not show up for work
more regularly. He has been skipping work after times of being blacked out and not
remembering his actions. Joe does not have many opportunities to increase his income and
has no aspirations for a better job fearing doing something different. Also, it seems as
though the more worried he is, the more he gets upset by things that happen around
him.When asked, Joe says he wants change and become a man like his grandfather.
However, he does not see a way out, especially if he is convicted of manslaughter. The
thought of spending time in prison terrifies him.(Source:
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A88941#A8906
8Initial Assessment / Mental Status CheckName of Client
________________________________________________ Date_____________________Appearance:__Well
groomed __Neat __Casual __Unkempt __Unclean __Inappropriate __Bizarre __Unusua
lGeneral
Presentation:__Cooperative __Guarded __Distractible __AgitatedSpeech:__Clear __Tone
(loud/soft) __Rhythmic __Poverty of
Speech __Rapid __Slow __Stutter __Pressured __SlurredAffect:__Appropriate __Blunted
__Melancholy __Restricted __Labile __Inappropriate __FlatMood:__Even __Depressed/s
ad __Anxious __Irritable __Angry __Elevated __Euphoric/elated __Expansive __Passiv
e __Pessimistic __BluntedOrientation:__Time __Place __PersonIntelligence
Level:__High __Average __Low __RetardedJudgement:__Rational __Impaired __Immatu
re __ImpulsiveInsight:__Emotional __Intellectual __Denial __Blames Others __Blames
Self __Slight Awareness __ Acknowledges problemThought Content:__Logical/Reality
Based __Delusions __Obsessions __Tangential __Illogical __Loose
Associations __Hallucinations __Ideas of reference/influence __Compulsions __Flight of
Ideas __Circumstantial __Inhibited __Concrete
__AbstractComments: _______________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_____RISK STATUS CHECKViolence/Abuse: (Domestic and Workplace, Child and
Sexual)Present
Risk: ____None ____Low ____Moderate ____HighCurrent: ________________________
_________________________________________________________________________________________________________
______________________________________________________________________________Past:

5. _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_Suicide/Homicide: (Past attempts, Prior inpatient admissions, Ideation, Intent, Attempt,
Plan, Compromised ADL’s)Present
Risk: ____None ____Low ____Moderate ____High
Current: _______________________________________________________________________________________________
______________________________________________________________________________________________Past: ____
_________________________________________________________________________________________________________
_____________________________________________________________________________________________________Oth
er risks: (eating disorder, history of multiple diagnoses, non-compliance with earlier
treatment, runaway):
_________________________________________________________________________________________________________
_______________Symptoms: Weight gain/loss Sleep decreased/increased Concentration
increased/diminished Interest level decreased FearRestlessness Increased
arousal Racing thoughts Irritability Avoidance Hopelessness CLIENT
RESOURCESStrengths identified by client
_________________________________________________________________________________________________________
_______________________________________________________________________________________Additional
client strengths seen by clinician
_________________________________________________________________________________________________________
___________________________________________________________________________Family members/others
who will be supportive of client in treatment
_________________________________________________________________________________________________________
_______________________________________________________Family member/support people to have
involved in treatment
_________________________________________________________________________________________________________
_____________________________________________________________ CLINICAL ASSESSMENT/DIAGNOSTIC
SUMMARY(Evaluate, integrate and summarize the following information: Background,
medical, social, presenting problem, signs & symptoms and impairments. Tie these in with
the patient’s strengths and needs. Integration of data is more important than specific
details.)________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
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6. _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
____________________ DIAGNOSIS Axis
I ________________________________________________________ _________________________________
_______________________ Axis
II ________________________________________________________ Axis III
________________________________________________________ _________________________________________
_______________ Axis IV
________________________________________________________ _________________________________________
_______________ Axis V Current GAF: __________ Highest past year
_____________ PROGNOSIS ____Excellent ____Good ____Fair __
__Guarded ____Poor Comment:
_________________________________________________________________________________________________________
_____________________________________________________________________________________________________
Treatment Plan Psychological theory and
explanation of fit (humanistic, behavioral, psychodynamic, cognitive, social-learning, self
theories): Therapy Choice and Treatment
Strategy: Particula
r Goals and Objectives (interventions) for
client: 1._________________________________________________________ _____
____________________________________________________ ____________________________________________________
_____ _________________________________________________________ a._______________________________________
____________ b.___________________________________________________ 2.
_________________________________________________________ _______________________________
__________________________ _________________________________________________________ ___________________
______________________________________a.___________________________________________________
b.___________________________________________________ 3.__________________________________
_______________________ _________________________________________________________ ______
___________________________________________________ _____________________________________________________
____a.___________________________________________________ b.______________________________
_____________________ Summary: Summarize the case study with the diagnosis
and plan of action. Explain why the treatment plan chosen is the best. Critique the plan and
explain where ethical and cultural considerations may arise and what could be done to
provide ethical and culturally sensitive treatment.