29 Mar Comprehensive Evaluation Note Template
FAMILY ASSESSMENT
Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues.
To prepare:
Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.
Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.
View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.
* Masterswork Productions. (2003). Mother and daughter: A cultural tale Links to an external site. [Video/DVD]. https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale
* Masterswork Productions. (2003). Mother and daughter: A cultural taleLinks to an external site. [Video/DVD]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale
THE ASSIGNMENT
Document the following for the family in the video, using the Comprehensive Evaluation Note Template:
Chief complaint
History of present illness
Past psychiatric history
Substance use history
Family psychiatric/substance use history
Psychosocial history/Developmental history
Medical history
Review of systems (ROS)
Physical assessment (if applicable)
Mental status exam
Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria
Case formulation and treatment plan
Include a psychotherapy genogram for the family
Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.
LEARNING RESOURCES
Required Readings
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
Goldenberg, I., Stanton, M., & Goldenberg, H. (2017). Family therapy: An overview (9th ed.) Cengage Learning.
Chapter 2, “Family Development: Continuity and Change”
Chapter 8, “Transgenerational Models”
Therapist Aid. (2012–2020). Genograms for psychotherapy.Links to an external site. https://www.therapistaid.com/therapy-guide/genograms
Therapist Aid LLC. (© 2012-2020). Genograms for psychotherapy. https://www.therapistaid.com/therapy-guide/genograms
Document: Comprehensive Psychiatric Evaluation Note TemplateDownload Comprehensive Psychiatric Evaluation Note Template
Document: Comprehensive Psychiatric Evaluation Note Exemplar Download Comprehensive Psychiatric Evaluation Note Exemplar
Optional Resource
Kaplin, D. (2021, Nov. 5). Family systems therapyLinks to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=UVPENypTc4k
Required Media
Gehart, D. R. (2013, August 29). Progress note Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=CEB1vBObUqc
Masterswork Productions. (2003). Mother and daughter: A cultural taleLinks to an external site. [Video/DVD]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practiceLinks to an external site. [Video]. https://waldenu.kanopy.com/video/counseling-and-psychotherapy-theories-contex
Family Systems Therapy (starts at 4 hours)
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