Assignment Question
With the client you selected in mind, address in a client termination summary (without violating HIPAA regulations) the following:
· Identifying information of client (e.g., hypothetical name and age)
· Date the client initially contacted therapist, date therapy began, duration of therapy, and date therapy will end
· Total number of sessions, including number of missed sessions
· Whether termination was planned or unplanned
· Presenting problem
· Major psychosocial issues
· Types of services rendered (e.g., individual, couple/family therapy, group therapy)
· Overview of treatment process
· Goal status (goals met, partially met, unmet)
· Treatment limitations (if any)
· Remaining difficulties and/or concerns
· Recommendations
· Follow-up plan (if indicated)
· Instructions for future contact
· Signatures
ANSWER
· Identifying information of client (e.g., hypothetical name and age)
Patient RA is a 42years old Caucasian male unemployed retired army.
· Date the client initially contacted therapist, date therapy began, duration of therapy, and date therapy will end.
Client contacted the therapist on November 24th 2020.
The therapy began on November 30th year 2020.
Duration is 12 sessions twice per week.
Therapy will end on February 8th year 2021.
· Total number of sessions, including number of missed sessions.
Twelve sessions
Attended eleven sessions and missed one session.
· Whether termination was planned or unplanned
Termination was planned from the beginning of the therapy.
· Presenting problem
I need help on how to cope with my anxiety problem and PTSD.
· Major psychosocial issues
Anxiety, molestation, flashbacks, dissociative amnesia, irritable behavior and anger, feelings of detachment, hypervigilance when in crowds, problem with concentration, sleep disturbance.
· Types of services rendered (e.g., individual, couple/family therapy, group therapy)
Individual therapy, group therapy rendered.
· Overview of treatment process
Thorough medical examination or thorough initial evaluation done.
Psychotherapy done for example education about relaxation and simple relaxation exercises, coping skills taught, hypnotherapy performed, PE, CPT, SIT.
Medications prescribed by the psychiatrist.
Self-help.
· Goal status (goals met, partially met, unmet)
Goals met.
· Treatment limitations (if any)
The only treatment limitation is EMDR (Eye Movement Desensitization and Reprocessing) not able to perform because the therapist not expert in it.
· Remaining difficulties and/or concerns
The remaining concerns is ability of my client to be more comfortable with others and crowds.
For his sleep pattern to improve more.
· Recommendations
Educated my client about how to maintain the gains made during times of stress and explore expectations about accessing resources in the future.
Reach out and ask others for help in order to relieve some of the stresses of daily life.
To be able to put more energy into his emotional healing process.
Join group and participate for example contact U.S. Veterans Administration National Center for PTSD.
