Comprehensive Client Family Assessment: Progress Note

Date of Exam: 15/10/2017

Time of Exam: 2:00 PM

Juan Hernandez is an eight-year-old boy, Juan shows a lot off change. Juan does not exhibit any symptom which can be described as mental anxiety or even depression. He seems to be having a future disturbance which has lead the family in attending mental agency for children counseling such brought of a child may lead to depression to the child which may even become fatal in future. Juan is living well, he has no any complication in his body, and the parent may be suffering from depression which makes them punish their child in such a way. The parents seem to be mentally weak and do not understand their child. The parents may even be suffering from certain guilt.

The content of therapy: Juan and his parents were advised to visit a local community mental agency, this is because of the parent physical punishment to Juan who seems to be harmless and is of good health both physically and mentally. The punishment may lead to depression to healthy Juan, which can lead to fatal though. The parents have severally been punishing their child Juan, with kneeling down while holding two encyclopedia books. The parents may be having some depression or some guilt which is affecting them to punish their child.



Therapeutic Interventions: the important therapeutic techniques used in the therapy session was to help in finding the areas which have difficulties, where there will be the development of

coping skills and also a way of managing stress. The session was to have the parents develop self-awareness and compassion. The parents will have to be able to see their selves and the child in a more positive way. The child should be able to forget the past and forgive his parents and be able to move on with his life in a more positive way. The child also needs to be able to make positive remarks at the end of the session and also be able to cope up with stress life.

Mental Status: the child has no sign of irritable or distracted, the patient has a full communication, he is always well groomed and appears to be normal. He also exhibits a normal speech rating, volumes and also its articulation is coherent and also spontaneous. He has an intact language speech. He has normal l mood with no signs of depression; he also does not have mood elevation as there are no physical changes to him, as he also eats as normal. All his physical and mental tests are normal. The parent has bizarre behavior, in a psychotic process, they seem to have depression lead by their quick marriage which they have now directed their depression to their child. There cognitive functioning and the fund of knowledge I not positive, but their son cognition is positive. The son is average, but with the risk of having depression, the parents seem depressed and not happy.

Diagnoses: below are the diagnoses which are based on the current information; the diagnosis can change with a change to any additional information.



The link treatment plan is depression, with the parents.

In the short term goals, the parents may have the depression symptom in less than 50% in a month. The target day is on 15/11/2017.

There was progress as the parents need more family together, they need to celebrate their life as parents and Juan as their son. They also need to have a social support from their family and friends.

Privilege Note

The patient’s estimated medical checkup of physiological functioning appeared relatively unhealthy due to diabetes, however, he showed short-lived anger management issues to stressful events. The patient demonstrated no slight difficult in relational and working functioning. The patient’s affective states appeared agitated and depressed. He has no drug-related issues but he has engaged in criminal history. The patient has the history of involvement in punishment. Both parents were involved in the appointment. It was noted that Juan has anger towards counselor

The main themes of the psychological session were: effective and safe discipline skills, developing age-appropriate behavior, boosting self-esteem, developing the sense of confidence and managing the frustration. The main therapeutic interventions designed included: parenting



sessions for parents to teach effective discipline skills, role-playing where both parents and the patient are involved in understanding feelings of each other and interpretations of barriers

regarding enjoyment. It was noted that the patient continues to make good progress upon understanding anger management. Developments are in progress in family and relational aspects. They are also expected to manage frustration as a family. Treatment will continue as indicated.

The psychotherapy notes capture the data of the patient, the type of assessment carried out and the plan laid for the therapy (DHHS, 2002). The note can have a different format, use SOAP which capture statement, objective data, assessment and plan. Psychotherapy notes exclude the time duration of the counseling, the modalities of treatment and results of tests. This information is excluded to guard patient safety and to protect sensitive information. My preceptor uses the psychotherapy notes are personal notes as they are intended for the therapy session. Additionally, they have little help to medics who are not involved in the therapy (Abeles, 2011).

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