Diagnosis and Treatment plan for Leslie

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Occupation: Rehabilitation Therapist

Family:

Married to her husband, John, for 18 years

Two daughters, ages 15 and 17

Reports that her marriage is “healthy”

Symptoms:

Has struggled with her weight for eight years

Binging and purging for the previous six months

Fatigue

Education: Undergraduate degree

Trauma History:

Sexually abused by an uncle at 12 years of age

Daughter, age 15, was raped by a classmate while attending a party

Current Treatment:

Recently attended therapy for three months but stopped

Felt she was not receiving any benefit from therapy

Treatment History:

Attended therapy for bulimia as a teenager

Hospitalized for four weeks

Did not continue therapy after discharge due to lack of money

Medication:

Adivan to ease anxiety attacks

Demographics:

Leslie is a 54-year-old Caucasian female. Leslie has her undergraduate degree in rehabilitation therapy and works as a rehabilitation therapist in a local treatment center. Leslie has been married to her husband, John, for 18 years and has two daughters, ages 15 and 17. Leslie reports that her marriage is “healthy.”

Treatment History:

Leslie reports that she attended therapy in her teens for bulimia. Leslie reports that she was hospitalized for 4 weeks due to her medical condition that resulted from her bulimia. Leslie says that she was supposed to attend individual therapy after discharge, but did not. She states “my parents couldn’t afford to continue my therapy and I felt that was okay.”

Current Treatment:

Leslie reports that she recently ended therapy with her therapist. They had worked together for 3 months. Leslie reports “I just didn’t feel like I got anything out of it.” Leslie has a prescription for Adivan (sedative). Leslie reports that her primary care physician prescribed the drug to help with anxiety attacks.

Current Medical:

Type 2 Diabetes; Morbid Obesity

Presenting Issue:

Leslie reports that “I have been binging and purging again.” Leslie reports that she has been struggling with her weight for the last 8 years, and 6 months ago began purging again. Leslie reports that she is fatigued and works long hours at her job. She feels like she never has any time with her family.

Trauma History:

Last year, Leslie’s 15-year-old daughter was raped by a classmate while attending a party. Leslie reports that the police were contacted the assailant was charged with the assault. The court date

is currently pending. Leslie reports that she was also abused as a child and her daughter’s victimization seemed to provoke flashbacks for her. Leslie was sexually abused by an uncle at 12 years of age.

PCN-488 Treatment Plan Template

Directions: Complete the treatment plan template for your chosen case study. An example has been provided for you. Once the table is completed, address the prompts listed below the table. Each response to the prompts listed below the table should be 50 to 100 words.

Example:

When was this goal created?

In the clients own words : “I want to worry less”

In clinical words, what will it look like by the end of treatment? Relate back to the problem statement.

Client will reduce worry from daily to weekly

What methods of treatment and frequency will you use to achieve treatment goals?

Weekly talk therapy meetings. Weekly DBT

How long will treatment be?

Client will attend individual therapy for 8 weeks; client will attend group therapy for 13

When will this particular goal be achieved?

Client reduce worry from daily to weekly by 3/15/17

Client Name: <Enter Client name>

Client Signature and Date

Counselor Signature and Date

Client Needs:

Client Needs Requiring Referral:

Assessment Criteria to Use When Treating the Client:

Using the Chosen Assessment Criteria, Analyze the Results of the Assessment for the Chose Case Study:

Potential Community Resources (in your local community) for Helping the Client:

How the fear of hospitalization affects the treatment plan: