b’xc2xa0Prepare A Genogram For The Client You Selected. The Genogram Should Extend Back By At Least Three Generations (Great Grandparents, Grandparents, And Parents) I will provide a client without violatin’

b’nxc2xa0Prepare A Genogram For The Client You Selected. The Genogram Should Extend Back By At Least Three Generations (Great Grandparents, Grandparents, And Parents) I will provide a client without violating HIPPA these are the areas need to be addressed in the genogramDemographic information Presenting problem History or present illness Past psychiatric history Medical history Substance use history Developmental history Family psychiatric history Psychosocial history History of abuse/trauma Review of systems Physical assessment Mental status exam Differential diagnosis Case formulation Treatment planxc2xa0Pain Today (0-10): Pain is described as 1 out of 10. xc2xa0Allergies: NKDA xc2xa0SLEEP ISSUES: Hours of sleep per night: 6-7 Snores: No Sleep latency: 0-15 min Daytime Somnolence: No xc2xa0xc2xa0Substance History: Caffeine Use: No Cups/Date Equivalent: Tobacco/e-cigs: none Packs/Date Equivalent: Illicit drug use: denied xc2xa0xc2xa0DEVELOPMENTAL/SOCIAL HISTORY: Patient reports that he grew up in Mississippi. His father died in a motor vehicle accident when he was several months old. Raised by his mother and stepfather. Denies any abuse history. Never married. Has a bachelorxe2x80x99s of arts in communication from Grambling UNIV. reports that he worked at Lowexe2x80x99s during college and thereafter. Is an AGR Soldier within the United States Army reserves in Mississippi from 2012-2018. States that his religion and spiritual values preference being Christian. xc2xa0Patient was primarily raised by Biological parents and that childhood was generally Good. Patient denies ever being physically, sexually or emotionally abused. Highest level of education achieved is: 4-year college degree or equivalent. Patient is currently single and currently lives with Other. Housing is currently Off-Post. Patient reports religion, faith or spirituality DO play an important role in life. Social support reported as satisfactory. Patient reports the following history of legal issues: None of the above. xc2xa0PAST FAMILY/MEDICAL HISTORY: Family Medical Illnesses: None Family Behavioral Health Illnesses: None Family Substance Use History: None xc2xa0OBJECTIVE MSE Orientation: xe2x98x90None xe2x98x92Place xe2x98x92Object xe2x98x92Person xe2x98x92Time Attention: xe2x98x92Normal xe2x98x90Distracted xe2x98x92Other: Maintained focus and attention throughout the session. Appearance: xe2x98x92Neat xe2x98x90Disheveled xe2x98x90Inappropriate xe2x98x90Bizarre xe2x98x92Other: dressed in civilian attire. Behavior: xe2x98x92Cooperative xe2x98x90Guarded xe2x98x90Withdrawn xe2x98x90Agitated xe2x98x90Stereotyped xe2x98x90Aggressive xe2x98x92Other: calm Eye Contact: xe2x98x92Normal xe2x98x90Intense xe2x98x90Limited xe2x98x92Other: maintained appropriate eye contact during the session. Psychomotor: xe2x98x92Normal xe2x98x90Restless xe2x98x90Tics xe2x98x90Slowed xe2x98x90Other Speech: xe2x98x92Normal rate, volume, and rhythm xe2x98x90Tangential xe2x98x90Pressured xe2x98x90Impoverished xe2x98x90Other Mood: xe2x80x9cI feel good overall.xe2x80x9d Affect: xe2x98x92Congruent with mood xe2x98x92Euthymic xe2x98x90Anxious xe2x98x90Angry xe2x98x90Depressed xe2x98x90Euphoric xe2x98x90Irritable xe2x98x90Constricted xe2x98x90Flat xe2x98x90Labile xe2x98x90Other Thought Process: xe2x98x92WNL xe2x98x90Circumstantial xe2x98x90Tangential xe2x98x90Loose Associations xe2x98x90Disorganized xe2x98x90Other Thought Content: xe2x98x92WNL xe2x98x90SI xe2x98x90HI xe2x98x92 potentially paranoid xe2x98x90A/V hallucinations xe2x98x90Delusional xe2x98x92Other: Denies SI/HI plan or intent Memory Impairment: xe2x98x92WNL xe2x98x90Short-Term xe2x98x90Long-Term xe2x98x90Other Insight: xe2x98x90Good xe2x98x92Fair xe2x98x90Poor Comments: Judgment: xe2x98x90Good xe2x98x92Fair xe2x98x90Poor Comments: xc2xa0BHDP: Behavioral Health Vitals (patient reported): Overall health reported as: Good Pain Level (0-10): 0 Currently treated: N/A Suicidal Ideation Risk – C-SSRS-S score: 0 Past/Prep Behavior last 3 months: N/A # past attempts as of 12/07/2016: 2 Most recent Suicidal Ideation: N/A Suicidal Ideation Duration: N/A Suicidal Ideation Frequency: N/A Protective Elements Stopping Suicidal Actions: Faith/Religion, Family, Hope for future, Friends, Other Harm Others Risk over next week as of 12/18/2018 – None Active Plan: N/A Patient with access to weapons: No xc2xa0Recent Outcome Measures (last 30 days) BASIS24 – Score: 0.56 – Subclinical to low level of general distress reported (12/18/2018) PHQ9 – Score: 4 – Depressive syndrome unlikely (12/18/2018) GAD7 – Score: 3 – Anxiety syndrome unlikely (12/18/2018) PCL-5 – Score: 3 – None-Low PTSD symptoms reported (12/18/2018) PCL-C: N/A AUDIT: N/A CSI – Score: 8 – Possible relationship distress reported. Evaluation indicated. (11/30/2018) ISI – Score: 9 – Subthreshold insomnia (12/18/2018) BAM: N/A xc2xa0LABORATORY RESULTS: Reviewed laboratory results xc2xa0ASSESSMENT Patient Strengths: xe2x98x90 None reported xe2x98x90 motivated xe2x98x90 insightful xe2x98x90 committed xe2x98x90 Tx compliant xe2x98x92 family support xe2x98x90 social support xe2x98x90desires change xe2x98x90 previous positive BH experience xe2x98x90 desire to address longstanding issues xe2x98x92 good expressive language xe2x98x90 good ego strength xe2x98x90 Other: xc2xa0Patient Barriers: xe2x98x90 None reported xe2x98x90 unmotivated xe2x98x90 limited insight xe2x98x92 uncommitted xe2x98x90 Tx non-compliant xe2x98x90 limited family support: xe2x98x90resistant xe2x98x90co-morbid Dx xe2x98x90 previous negative BH experience xe2x98x92 limited social support xe2x98x90cognitive impairment/TBI xe2x98x90low ego strength xe2x98x92 Other: Not resistant but questions the validity of his behavioral healthcare xc2xa0SAFETY RISK ASSESSMENT xe2x98x90YES xe2x98x92NO History of Suicidal Ideation: xe2x98x90YES xe2x98x92NO History of Suicidal Planning: xe2x98x90YES xe2x98x92NO History of Suicidal Gestures: xe2x98x90YES xe2x98x92NO History of Suicidal Attempts: xe2x98x90YES xe2x98x92NO Close friends/family who have attempted/completed suicide: xe2x98x90YES xe2x98x92NO History of intentionally harming others or destroying property: xe2x98x90YES xe2x98x92NO Current intentions to engage in above behaviors: xe2x98x90YES xe2x98x92NO History of impulsive-taking: xc2xa0Risk Factors: xe2x98x90None reported xe2x98x92Male xe2x98x90Impulsive xe2x98x92Weapons access xe2x98x90Legal Stressors xe2x98x90Financial Stressors xe2x98x92Occupational conflict xe2x98x90Chronic medical problems xe2x98x90Substance abuse: xe2x98x90Abuse victim: xe2x98x90History of suicidal gestures xe2x98x90History of family/friend suicide xe2x98x90Relationship problems xe2x98x90OTHER: insomnia xc2xa0Protective Factors: xe2x98x90None reported xe2x98x90Married xe2x98x90Children xe2x98x92Positive religious coping xe2x98x92Future orientation xe2x98x92Healthy coping skills xe2x98x90Active treatment participation xe2x98x92Supportive spouse xe2x98x90Supportive family xe2x98x90Social support xe2x98x92PT wants to continue treatment xe2x98x90OTHER: xc2xa0This provider considered the above risk/protective factors and has determined the following risk level: RISK: Harm to Self xe2x80x93 xe2x98x92Not Elevated xe2x98x90Low xe2x98x90Intermediate xe2x98x90High Harm to Others xe2x80x93 xe2x98x92Not Elevated xe2x98x90Low xe2x98x90Intermediate xe2x98x90High SAFETY:xe2x98x90YES xe2x98x92NO Imminent threat to self. xe2x98x90YES xe2x98x92NO Imminent threat to others. xe2x98x90YES xe2x98x92NO Imminent threat of harm from other individuals. xe2x98x92YES xe2x98x90NO Patient is fully able to make informed medical decisions and manage affairs. xe2x98x92YES xe2x98x90NO Patient is unlikely to withhold information about SI/HI ideation or intent. xe2x98x92YES xe2x98x90NO Patient is considered to be a reliable source of information. xc2xa0DIAGNOSTIC FORMULATION: This is a 35-year-old male who was deployed to the Middle East as an individual unit augmentee. He reports that he became an conflict with his leadership over mishandling funds, and other ethical related issues. The unit is making the claim that the patient is misperceiving these incidences, based off of the provider assessment in-theater; paranoia over this situation was identified. xc2xa0DSM Diagnosis(es) Code: Other occupational structure stressors R/O: Delusional Disorder, psychosis xc2xa0Estimated Treatment Prognosis: Good . xc2xa0PLAN Treatment Summary: 1) Patient was provided psychoeducation, assessment of current functioning, risk/safety assessment, development of rapport, development of treatment goals, empathic listening and directed questioning techniques to elicit information and provided supportive environment to facilitate patient insight. Patient was provided active listening, strategic reflection, encouragement and validation. Other therapies discussed include: 1. Diaphragmatic Breathing 2. Progressive Muscle Relaxation 3. Safe Place Imagery 4. Mindful breathing 5. Problem solving techniques 6. Sleep Hygiene 7. Discussed, Virtual Hope box, Tactical Breather, Moving forward and Mindfulness coach apps available on smart phone. xc2xa02) Discussed open-access clinic available at BH clinic. Pt agree if symptoms worsen or if new behavioral concerns arise, Pt to call, RTC, or if after duty hours, go to ED and/or call emergency line. Limits to confidentiality were discussed with the patient as appropriate. xc2xa03) Attending behavioral health group for deployed service members on Monday, Tuesday, Thursday and/or Friday from 1430-1600. xc2xa0Medications: None xc2xa0Risk/Suicide Management Plan: xe2x98x92YES xe2x98x90N/A The patient will follow-up in therapy to address treatment goals. xe2x98x92YES xe2x98x90N/A The patient has demonstrated the ability to and has agreed to make use of a crisis response plan. xe2x98x90YES xe2x98x92N/A The patient was added to the High Interest Program to track continuity of care. xe2x98x90YES xe2x98x92N/A Persons notified: xe2x98x90YES xe2x98x92N/A Emergency Contacts: xe2x98x92YES xe2x98x90N/A Emergency Contacts and Crisis Response Plan: Call friends, family members, or a trusted chaplain. Contact Military One Source at http://www.militaryonesource.mil/ or call 00-800-3429-6477. Call Wounded Soldier and Family Hotline at OCONUS DSN 312-421-3700. Access www.realwarriors.net/livechat for online chat support. After duty hours, call 112, call MPs, First Sergeant or primary supervisor if feeling suicidal. During duty hours, walk in to Behavioral Health Clinic. Go to the Emergency Room at Landstuhl Regional Medical Center. They will call the on-call Behavioral Health Provider. xe2x98x90YES xe2x98x92N/A Safety plan worksheet uploaded into HAIMS.xc2xa0 ‘