Instructions The completed workbook is required to be between 5 to 8 pages long,

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Instructions
The completed workbook is required to be between 5 to 8 pages long, double spaced and using a 12 inch font. Your cover page and reference page do not count toward the required number of pages.
Section One is required to be 2-3 pages long.
SECTION 1A: Mental Status Exam (at least 1 paragraph)
Take a complete but brief Mental Status Exam (MSE) of your client. Your MSE must include all of the following categories below:
General Description
Appearance
ability to maintain eye contact
appropriateness of dress for the situation
cleanliness
grooming
posture
general constitution
physical build
Behavior
Psycho-Motor Activity (manner of walking, sitting in chair, picking up and handling objects)
Attitude Toward You
Mood and Affect
Mood (the emotional state maintained throughout the interview)
Affect (the emotional tone conveyed by speech & behavior)
Appropriateness to Situation
Stability or Rapidly Changing
Variation in Range ( emotional tone changes as topics change)
Speech Quality
rate
amount
rhythm
tone
volume
Thought
A. Process of Thought
answering questions before you finish asking them
long pauses before answering a question
sudden stops in the middle of a thought
flight of ideas (numerous unrelated or illogical group of thoughts)
B. Content of Thought
delusions (firm, fixed, false beliefs that are not culturally or religiously determined)
grandiosity (inflated sense of self importance or abilities than anyone else)
hallucinations (perceptions of things that are not there)
illusions (misperceptions of things that are there)
paranoia
ideas of reference (perceptions that unrelated facial expressions or comments by others are about you)
thought insertion (people can put thoughts in your mind)
thought withdrawal (people can remove thoughts from your mind)
circumstantial (provides unnecessary details but answers your question)
tangential (initially answering your question but then adds information unrelated to your question)
Impulse Control (thinking before acting)
Judgment (able to compare choices in decision making) and Insight (self-awareness, denial or acceptance that there is a problem)
Reliability (able to report information accurately)
SECTION 1B: Identification and Family Background (at least 1 paragraph)
Describe age, gender, sexual identity (one’s sense of self as a sexual person), sexual orientation (one’s romantic and sexual attraction towards others), race/ethnicity, religion, social class, financial/employment status, significant family of origin and/or family of choice, history of losses, separations in and additions to the family, homelessness and food insecurity. Discuss intersectionality (multiple social roles), marginalized identity status and the impact of microaggressions, oppression, and trauma. Describe the client’s past and current social support systems.
SECTION 1C: Symptom Picture (at least 2 paragraphs)
Describe your chosen client’s symptom picture. Your description should be specific and comprehensive. What is the presenting problem? Who/what is the referral source? Describe how the issue began and the circumstances when it manifests/happens/occurs.
Describe how you would use the AIM Model and the C-SSRS from the Week 4 module on Suicide Safer Care to assess your chosen client. Include what the results of this assessment would reveal.
SECTION 1D: Medical, Health, & Biological Issues (at least 1 paragraph)
Describe any current or past history of medical/health and mental health issues of your client. Your assessment should include any illnesses that currently are being treated, in remission or resolved. What are the biological factors at play, developmental delays, including heredity/genetic conditions, medication, substance use/dependence?
SECTION 1E: Cross-Cultural Considerations Related to Assessment (at least 1 paragraph)
In detail, please discuss any cross-cultural considerations relevant to your client’s assessment. Please address any systemic oppression, racism, sexism, homo/trans-phobia, criminalization of trans health, lack of reproductive freedoms and historical/inter-generational trauma at play.
SECTION II: Treatment Plans/Interventions
Section Two is required to be 3-5 pages long.
Consider the modalities and interventions discussed in this class so far:
Week 5: Trauma Focused-Cognitive Behavioral Therapy
Week 6: Problem Solving Therapy
Week 7: Behavioral Activation
Week 8: Interpersonal Therapy
Week 9: Dialectical Behavior Therapy
Choose a modality you believe will be of most help to your chosen client. Explain your reasoning about the modality you chose. Support your decision with course reading materials. Be sure to cite your sources in the text of your workbook & on a separate references page using the APA 7th Edition citation style.
Discuss three overall treatment outcomes/goals for your client consistent with your chosen modality. Explain your reasoning for choosing these outcomes/goals.
Describe your how you would measure progress for your client and the types of measures you would use.
Describe two specific activities or modality techniques you would use with your client and how your client might respond to them.

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