Create a Comprehensive Psychiatric Evaluation Note on the following patient with conduct disorder using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide.
This note provided below is from an established visit with the therapist.
“18 yo M client discusses his recent moods and functioning. Offered praise for his continued abstinence from marijuana and his upcoming termination from probation. Checked in regarding any urges he may have had to smoke marijuana and how he has been able to resist. Led him in reviewing The Recovery Process Worksheet to explore common steps to recovery including asking for help, developing self-awareness, recognizing problems, choosing to make changes, learning new ideas, recognizing choices, hearing feedback from others, etc. Elicited from him, what steps he felt he completed. Normalized experiencing steps of recovery in different orders, repeating certain steps, or skipping steps. Processed thoughts and feelings as they came up in terms of his recovery. Helped client to recognize the need for him to identify intrinsic value in remaining sober as he will soon no longer have probation as a motivator.”
Other pertinent information:
Presented to court-ordered therapy. Caught stealing beer from the convenient store at age 16. Been on probabtion for over a year. He was skipping school, when he was in school he was fighting all the time, he’s disobeying guardians, not coming home some nights. Grandparents took over care at age 13. Dad has been in jail since he was 2 months. No contact with him. Mom disappeared a lot or was high most of the time. No known family history of mental health disorders. Has never been diagnosed with mental health disorders or taken psych medications. No medical history.
No known allergies.
No current friends as the ones he had were a group he would get in trouble with.
No job. No car. No significant other. Does not have driver’s license.
Any other information can be made up.
