Nursing assessment. | NURS 6640 – Psychotherapy With Individuals | Walden University

Learning Objectives

Students will:
  • Assess clients presenting for psychotherapy
  • Develop genograms for clients presenting for psychotherapy

To prepare:

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  • Select a client whom you have observed or counseled at your practicum site.
  • Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.

The Assignment

Part 1: Comprehensive Client Family Assessment

With this client in mind, address the following in a Comprehensive ClientAssessment (without violating HIPAA regulations):

  • Demographic 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 plan

Part 2: Family Genogram

Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).

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