Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues.
To prepare:
• Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples. ( See attachment)
• Be sure to review the resource on psychotherapy genograms. – See attachment
• View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study. – See transcript – Attachment
The Assignment – Instructions
Document the following for the family in the video, using the Comprehensive Evaluation Note Template (attachment):
• Chief complaint
• History of present illness
• Past psychiatric history
• Substance use history
• Family psychiatric/substance use history
• Psychosocial history/Developmental history
• Medical history
• Review of systems (ROS)
• Physical assessment (if applicable)
• Mental status exam