CCMH 558 Wk 5 – Summative Assessment: Biopsychosocial Assessment with Case Conceptualization and Treatment Plan

A counselor conducts a biopsychosocial assessment during intake to try to fully understand the client’s presenting issues and their subjective viewpoint. It assesses clients on 3 dimensions: biological, social, and psychological. As a result, biopsychosocial assessments provide vital information to aid counselors in the treatment and diagnosis of clients. From the information gathered, the counselor can begin to formulate a case conceptualization. A case conceptualization is a cognitive map used to understand and explain a client’s presenting issues and to guide the counseling process. Case conceptualizations provide counselors with a clear plan for focusing treatment interventions to increase the likelihood of the client achieving their treatment goals.

Imagine that you are the counselor in the following scenario—this is your initial session with the client. Following the session, you will complete a biopsychosocial assessment, case conceptualization, diagnosis and treatment plan based on the information presented. This assignment directly parallels what a counselor would do in real life at an agency following the initial session.

Watch “Intake Assessment” and conduct a biopsychosocial assessment of the client presented. If there is no Mini-Mental Status Exam completed, indicate that in the cognitive section of the Mental Status part of the assessment.

Note: A transcript of the video is available.

Although the case study may not provide in-depth information for all sections of the biopsychosocial assessment, please use the information as provided, and note if there is no information given for a specific area. Do not leave blanks—to document accurately and responsibly, you must note when information is missing.

Complete a Biopsychosocial Assessment form with case conceptualization for the case, using full sentences and appropriate grammar.

Diagnose the individual in the video based on the symptoms and the DSM-5 diagnostic criteria. Support your diagnosis in the summary section of the Biopsychosocial Assessment form. Your assessment should be a minimum of 500 words.

Include a minimum 100-word case conceptualization that explains the issues, symptoms, and diagnosis framed in a theoretical lens.

Research common treatment goals for the chosen diagnosis before completing your Treatment Plan form. Complete a Treatment Plan form for this client based on best practice or evidence-based therapy. Justify your treatment plan with peer-reviewed research. Your treatment plan should be a minimum of 200 words and include:

• A minimum of 2 target problems
• Specific, short-term goals for each target problem
• Objectives for each target problem
• Intervention strategies to achieve goals for each target problem
• A minimum of 2 academic, peer-reviewed sources to support the goals, objectives, and interventions for each target problem

Use the forms located on the College of Social and Behavioral Sciences Resources site for the College of Social Sciences Master of Science in Clinical Mental Health Counseling & Mental Health Counseling program.

Include a reference page in APA format for the case study you selected and any supporting resources used in your treatment plan.

Submit both completed forms and the reference page for your assignment.