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Bio-psychological Assessment
Personal data: fill as you see fit
Referral: depressed, poor sleep,
Family Background: raised by parents and older siblings
Family medical/psychiatric history: brother had heart attack; mother had issues with drugs and alcohol
Marital/family relationships: widow with four children and eight grandchildren
Social development: maintains friendships, supportive friends, attends social functions
Strengths: kind, nurturing, empathetic, understanding, calm
Weaknesses: can be impatient, overbearing with family members
Educational history: middle school
Employment history: retired; worked as live-in housekeeper for over twenty years
Military history: none
Spiritual assessment: attends Catholic Church regularly
Financial history: dependent on others
Patient health and psychiatric history: hypertension
Alcohol and drug abuse: none
Sexual identity and history: heterosexual
Physical, sexual, and emotional abuse and neglect history: none
Current living support system: lives with family
Identity: has insight
Ethnicity, culture, and values: Hispanic
Legal status and history: none; person entered U.S. As illegal immigrant but later acquired green card
High risk: Decreased intellectual functioning
Mental status exam: fill out as you see fit Summary: Mirta lives with her family, who assist her with daily living activities.She is mainly functional but recently lost her husband and so has had trouble sleeping and managing her depressed mood. Mirta's mental functioning is on the whole good but aging is starting to take a toll on her. To prevent further complications with her health, Mirta is advised to avail herself of professional counseling services but is unwilling to do so because she relies on the church and her family for support.
Social service plan/Problems Identified: Depressed mood, Sleep disorders, Decreased cognitive functioning
Social service plan/Method of Intervention: Encourage counseling, recommend a psychiatrist, recommend increased mental and physical activity to prevent health problems.
Treatment goals/short-term: manage moods, regulate sleep patterns
Treatment goals/long-term: maintain physical health and well-being, maintain mental acumen, monitor physical health continually
Preliminary discharge plan: before discharge one session with counselor or psychiatrist is recommended. Also, a meeting with family members present is recommended......