Assessment: Clinical Treatment And Observation

Clinical Treatment and Assessment Planning Intake 1
Marissa, a 17-year-old female was encouraged by her grandmother to seek professional therapeutic help. In meeting with Marissa on October 29, 2015, the therapist observed obvious discontentment in coming to the session. Marissa reported having a conflicted relationship with her grandmother, who is her sole caregiver. The patient also reported a recent change in her social network at school; where she once had close friendships with peers whom she grew up with, her current network includes peers with different interests. Marissa’s stated that her old friends are ‘lame,’ and she feels she is better understood by her current network of friends. The patient reported she often partakes in activities favored by her new peer network which includes skipping class, smoking marijuana, and occasionally drinking alcohol. Perhaps consequently, the patient also noted a …show more content…
If the patient had reported previous mental health concerns and/or previous involvement with a mental health professional, further investigation of the nature of the contact would have been warranted. The therapist could have asked Marissa what her reason(s) for seeking mental health services were, how long did she stay in treatment, what (if any) diagnoses were given, and what her overall feelings were toward the treatment she received. Furthermore, if Marissa had been previously received mental health services, a request for a release of information authorization could have been granted to gain additional collaborative information to inform her current treatment. Additionally, if Marissa had been involved in prior mental health services and received pharmacotherapy as part of her treatment, questions geared toward understanding the effectiveness of the medication(s), and if there were any adverse reactions to the medication(s) would have been