Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

(include psychiatric ROS rule out)

Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

Case Formulation and Treatment Plan:

Assignment: Family Assessment

Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues.

To prepare:

Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.

View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.

The Assignment

Document the following for the family in the video, using the Comprehensive Evaluation Note Template:

Chief complaint

History of present illness

Past psychiatric history

Substance use history

Family psychiatric/substance use history

Psychosocial history/Developmental history

Medical history

Review of systems (ROS)

Physical assessment (if applicable)

Mental status exam

Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria

Case formulation and treatment plan

Include a psychotherapy genogram for the family

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