Reference no: EM133140939

Identifying Information: Mr. John Smith, 40-year-old American white male born in Texas, Marriage over 7 years, with two kids, well-groomed, serve in the military over 15 years(Army).

Presenting Problem: Within months after serving and returning from deployment Mr. Smith showed signs of post-traumatic stress disorder (PTSD).  He needs to be physiological elevation at the VA assessment and treatment for his condition. 

History of Presenting Problem(s): flashbacks due to his (PTSD) Mr. Smith continues to feel confused, scared, nervous, isolated, wakes up from his sleep screaming and continues to have marital problems. As a result, he has a deep emotional scar that impacts his ability to function through economic or social challenges-readjusting to civilian life.

Social History: Smith is currently living with his family since his return from deployment. They chose to leave in an urban setting and had regular social activities to expose Mr. Smith to loved ones. 

Goals: Assess and evaluate his condition in order to provide suitable treatment for maximum results. Mr. Smith will be able to identify triggers.l and will eventually learn to cope through positive strategies. He can also control his emotions and learn relaxation techniques.

Plan: 

1) Name of agency, Name of Agency Supervisor 

2) client full name, age, demographics, family history, how many children, how long with the agency, presenting problem that brought the client to the agency etc

3) current issue / assessment (add critical details)

4) current set goals

5) positive progress

6) Challenges

7) Referrals