Cnsl 556 Case Conceptualization Treatment Plan
Case Conceptualization
Tameka Coleman
CNSL 556: Portfolio II
Jennifer Rousch, PsyD
February 6, 2015
CASE CONCEPTUALIZATION & TREATMENT PLAN
NAME: Liz
ADDRESS: 1444 No Where Lane
DATE OF BIRTH: 12-10-1980
PHONE: 951-777-9311
PRIMARY LANGUAGE: English
EDUCATION: High School
REFERENCE BY: Friend
OCCUPATION: Homemaker
ASSESSMENT DATE: 02/03/2015
EVALUATED BY: Tameka
DESCRIPTION OF THE CLIENT
The client is a 34-year-old woman Hispanic female, dressed casually and neat, clean clothing. She made normal eye contact, she spoke in expressive voice, and appeared sad manifested by tears.
PRESENTING PROBLEM
The client reports for the past two months she experiencing hopelessness, depression and anxiety because of negative core beliefs that she is inadequate, worthless and a failure.
The client reports “I have a lot on my mind, I feel pressure like I cannot breathe sometimes and I get angry with myself because I want to please everyone”. This has resulted in symptoms that are diminishing the enjoyment of her life. The client’s automatic negative thoughts that she is worthless and a failure has caused the client to stop doing things that used to bring her pleasure. The client reports that all of these emotions and conflict is affecting her. The client states she is tearful, always tired; restless; unable to feel pleasure; ambivalent suicidal ideations; anxious, unable to sleep; hopelessness; loss of appetite; despair; and fear.
HISTORY OF PROBLEM
The client reports that she and her husband have relationship conflict and communication problems which lead to arguing. The client states “he pushed and slapped me, he said that he would kill me or hurt me in front of my children. I felt the abuse was escalating so I took the children and moved in with my mother”. For the past two years her husband started drinking heavily and the physical abuse is escalating. She has been
Tameka Coleman
CNSL 556: Portfolio II
Jennifer Rousch, PsyD
February 6, 2015
CASE CONCEPTUALIZATION & TREATMENT PLAN
NAME: Liz
ADDRESS: 1444 No Where Lane
DATE OF BIRTH: 12-10-1980
PHONE: 951-777-9311
PRIMARY LANGUAGE: English
EDUCATION: High School
REFERENCE BY: Friend
OCCUPATION: Homemaker
ASSESSMENT DATE: 02/03/2015
EVALUATED BY: Tameka
DESCRIPTION OF THE CLIENT
The client is a 34-year-old woman Hispanic female, dressed casually and neat, clean clothing. She made normal eye contact, she spoke in expressive voice, and appeared sad manifested by tears.
PRESENTING PROBLEM
The client reports for the past two months she experiencing hopelessness, depression and anxiety because of negative core beliefs that she is inadequate, worthless and a failure.
The client reports “I have a lot on my mind, I feel pressure like I cannot breathe sometimes and I get angry with myself because I want to please everyone”. This has resulted in symptoms that are diminishing the enjoyment of her life. The client’s automatic negative thoughts that she is worthless and a failure has caused the client to stop doing things that used to bring her pleasure. The client reports that all of these emotions and conflict is affecting her. The client states she is tearful, always tired; restless; unable to feel pleasure; ambivalent suicidal ideations; anxious, unable to sleep; hopelessness; loss of appetite; despair; and fear.
HISTORY OF PROBLEM
The client reports that she and her husband have relationship conflict and communication problems which lead to arguing. The client states “he pushed and slapped me, he said that he would kill me or hurt me in front of my children. I felt the abuse was escalating so I took the children and moved in with my mother”. For the past two years her husband started drinking heavily and the physical abuse is escalating. She has been