Reference no: EM133242457

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Case Formulation and Treatment Plan

The client is evaluated for the following symptoms during today's assessment depression, anxiety, sadness, panic, impulsivity, suicidal ideation. The client's medication will increase Focalin XR to 15 mg QAM, and Zoloft 50 mg daily reconciled with any update to the therapeutic regiment and adjustment are reflect in the both the client chart and clinical note. Side effects responded by the client or that are assessed by the treating provider are documented in the chart with necessary adjustments or actions taken. Medical history is reviewed and updated per client report. Social history is reviewed and updated per client report. Medication educations/counseling provided was provide with following   education and verbalized understanding. Medication dose and time to take, purpose expected benefit sand risks of medicine. Common side effects expected length of treatment, financial assistance/availability, alternatives to prescription medicine, risks of medication non-adherence or refusal of treatment. In addition to the current identified client goal, the following general treatment goals were discussed with patient symptom reduction, medication adherence, maintain therapeutic gains, restore level of functioning, reduce reliance on medication for symptom management. Patient agrees to return to clinic sooner/call provider if suicidal/homicidal ideation occurs or if audiovisual hallucinations present or worsen. Client is advised to adhere to treatment plan(s) to prevent relapse and regression of progress. Client is advised of emergency services, including crisis Physical handout on local crisis hotlines are made available to client for convenience. Client/Guardian can call office or seek emergency services for acute worsening of symptoms or risk of danger to self or others. Crisis hotline information is additionally located on the practice's website. The client is encouraged to call these crisis lines if having after-hours suicidal or homicidal ideation as the client understands that the office will be unable to assist them with an emergency after hours. Client verbalized understanding of education about crisis line and consents to call if having after-hours issues. Labs / Referrals / Care Coordination: Referral has been made to outpatient counseling services.  The evaluation and management / integrated psychotherapy (Yin et al., 2021).  The practitioner and the client agree to work toward the following therapy goal(s): Enhance coping skills in an effort to help client cope with new situations and challenges, Promote behavioral change by enabling client to live a more productive and satisfying life‚ identifying specific and measurable goals to gauge client success, allow client to see how emotions‚ attitudes‚ and values influence decisions and choices, Promote positive decision making practices in an effort to assist the client make good decisions and realize the consequences of bad decisions. The client's progress toward therapeutic goals is assessed during today's appointment. The client is recommended to attend individual / group therapy in addition to pursing medication management services as the rendering provider believes that the client would benefit from additional therapeutic interventions and follow-up to realize proposed