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1 Practicum-Assessing Clients Shaundra Hudson Walden University NURS 6640 Psychotherapy with Individuals
2 Assessing Clients “A comprehensive assessment of the patient who presents for psychotherapy is necessary to develop an appropriate treatment plan. This assessment is a relational process that sets the tone for subsequent sessions” (Wheeler, 2014, p. 131). As a future Psychiatric Mental Health Nurse Practitioner, it is essential to be able to accurately assess clients to determine whether your therapeutic approach would contribute to improved clinical outcomes. The purpose of this assignment is to select a client that was observed or counseled at my practicum site and complete a comprehensive client assessment and genogram for the client selected. Comprehensive Client Assessment Demographic information for the client chosen is as follows: The client is a 27-year-old African female who resides in Maryland. She is a single, heterosexual, mother of fraternal twins, a boy and a girl. She was referred by her psychiatrist to the current counselor for psychotherapy and is primarily followed by the psychiatrist for medication management. The client has been receiving psychotherapy for the past two years. Her presenting problem revolves around learning how to be independent while coping with her mental illness. She stated, “I need help with figuring out my finances.” History of present illness: Client has a history of bipolar and presented to the office with complaints about her “baby daddy” not wanting to help her out with their children and about how difficult it’s going to be when her cousin stops keeping her twins because daycare is expensive. She also expressed discontent towards her father interfering in her psychiatric care because he shares the same Nigerian ethnicity as her psychiatrist and she wants to be on less medication and receives more psychotherapy. The client’s past psychiatric history includes two psychiatric hospitalizations for manic episodes with psychosis. Medical history includes a previous diagnosis of hypertension (HTN), but that diagnosis was later removed. The
3 client never took any medications for HTN diagnosis, and HTN resolved through life modifiers.

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