Running head: TREATMENT PLAN
Treatment Plan: Sally Smith
Jasmon L. Cox
Liberty University
Running head: TREATMENT PLAN
Dyvergence Health
... [Show More] Treatment Plan
PATIENT ASSESSMENT
Patient Name Sally Smith Date of Birth: 07/21/1978
Address
:
Sally Smith address Phone: 999-999-9999
Emergency Contact (s): Parents Other Care Plans:
Date of Examination: September 1, 2016
Examiners: Fred Looney, PhD
Data and
Relevant History
Sally Smith is a forty-two-year-old female. She has been evaluated with
an assessment to decide if she suffers from substance abuse and mental
health issues. She is an African American female that uses alcohol daily,
has a history of drug abuse, lives at home with her parents. Her
evaluation has determined cognitive, emotional, and substance abuse
issues exist based on her mood changes, drinking daily, and suicide
thoughts.
Smith’s absence from work is due to her deficient performance
responses mentally and emotionally to this behavior. Despite earlier
efforts, Smith’s addiction and mental health issues involves
uncontrollable activity that has contributed to distorted mood, thinking,
and behavior dynamics.
Sources of
Information
Sources of
Information
Clinical Interview with Sally Smith
Medical Records
Brief Mental Status Examination
Wechsler Adult Intelligence Scale-IV (WAIS-IV)
Running head: TREATMENT PLAN
Self-Reported
Information
Smith reported she was unemployed. She reports that her health is
declining, and her health’s declining developmental history includes high
blood pressure, drug uses with benzodiazepines and OxyContin. Smith
reported problematic drinking and suicidal ideations. Smith’s behavior
that she hears voices, and she talks to them. The validity of his report
was considered correct due to his cooperation and motivation to selfreport his behavior.
Present Issue (s) Sally is a forty-two-year-old female presenting mood and substance
disorders such as depressive symptoms, suicide, and alcohol abuse. She
has recently moved home with her parents. Her depression in life has led
to increased psychological stress during crucial growth time in Smith’s
life.
Medical History
(Physical Health)
Alcohol Poisoning, inflammatory bowel disease, acute gastritis, atypical
chest pain, hypertension
Medical History
(Mental Health)
Smith in 2016 was admitted to a state hospital due to her mental state at [Show Less]