This is the final written assignment in this course. Throughout the course, you should work to infuse information about your couple and identified patient (Jasmine) in each section. This template is

Written Clinical Assessment Report (CAR) [Final Project] - 180 points Assignment #8 This is the final written assignment in this course. Throughout the course, you should work to infuse information about your couple, family, and identified patient in each section. This template is suggested, however, it is recommended that you locate othe r example clinical assessment reports and juxtapose the information, look toward the research to see if there are other suggested format considerations , and use your own preferences as additional components or as a means to expound further on suggested sec tions. Part I: Demographic Information In part one, the demographic information includes the name or names of individuals being assessed, any aliases nicknames are made names are appropriate, the date or dates of birth, the age of the person coming to rep orted biological sex each person, their place Of residence, the parents employer, job titles if appropriate, and their levels of education and their credentials. Part II: Circumstances of Clinical Assessment Part two is the circumstances of the clinical as sessment. Here is where the purpose and the goals of assessment are addressed, treatment personnel or treatment team, the allocated time invested from beginning to end, and any synonymous language similar to what was defined earlier in video one of the cou rse. The purpose and goals of the assessment is just simply the reason why the assessment was conducted in the first place. The goals of the assessment are set so you as the clinician has clear direction on where you’re trying to get to once the assessment process has come to an end. The treatment personnel is normally a set. Where you highlight the qualifications of the licensed professional and then if there’re any additional affiliates employees or otherwise, like interns or assessment proctors , then you mention in the report those affiliates during this section and their purpose or role. In respect to allocated time coming This reveals the amount of time spent with the client in a face - to - face capacity and whether the time to analyze and inter pret the test results, along with write the report. Finally synonymous language is an area where terms are defined and described as interchangeable within the report. This is also a section where you can define technical terms for professional jargon used in your report writing. Part III: Clinical Assessment Procedures The clinical assessment process begins when an initial phone call and/or an inquiry is made online by a potential client, and continues throughout the therapeutic relationship. The assessme nt process is both inductive and deductive in nature, beginning with multiple data sets, a triangulation process that confirms or identifies glaring themes, and a diagnostic process. Couples and families have the right to enter into a relationship with the therapist for assessment purposes only, which does not require client to enter or remain as a client receiving mental health therapy services. The informed consent, intake forms, and release of information are addressed during this section of the report . An explanation of how or is that clients received the necessary forms to begin the therapeutic relationship, which would normally consists of a professional disclosure statement and informed consent, the adult and a minor intake forms, and client handboo k or manuals. Additionally if any releases of information are attained and for what purpose can be included. A statement regarding the limitations of the assessment, and how entities or organizations requiring these assessments may have their own criteria and documentation of the case, therefore it cannot determine the actions or outcomes of the entity is recommended. Then another section under Part III is the c onditions of a ssessment p rocess . It is similar to describing the conditions of the environment, whether or not it was comfortable, and if the client(s) had the necessary equipment or materials to partake in the assessment process. The next part is the diagnostic process. Statements should be made toward rendering a clinical diagnosis that consist s o f obtaining information from multiple sets of data. The i nformation gathered should address subjective data collected (e.g. self - report, case notes, job descriptions, and circumstantial documentation for review/analysis) and whether there were collateral informants. A discussion about the need to consult with other professionals can be mentioned. Examples of o bjective data collected are like the use of tests, observations, and an assessment of interactional and communication patterns. The types of assessments rendered are briefly mentioned in the next part of the report. If there is an assessment proctor, any observed behavior can be reported (i.e. mood, affect, apparent stress, resistance, body language, and tone of voice). For example, if a co uple’s assessment like Prepare and Enrich was administered, in the amount of time it took to complete the assessment would be noted. Part IV: Background and Historical Information The c lient or individual family members di sposition, m otivating f actors, an d d uration of t reatment is described in the section of the report . The disposition addresses behavior , emotions , and countenance in general, along with motivating factors to complete the process or for change, and the number of sessions required scheduled and the dates of attendance. Then, the family history and background information should be included. Information regarding individual family members experiences, strengths, hobbies, situational factors, parents relationships, medical conditions or health limitations, abuse or addictions, physiological symptoms, religion and spirituality, substance abuse or use, self - harming or suicidal risk, social and economic concerns, marital status and former relationships, and work - place circumstances. Part V: Emotio nal Sustainability (Stability, Maturity, Intelligence, and Regulation) Information in this section is an accumulation of observed behavior during your time spent with the family or couple. This section can address emotionality, members ability to regulate those emotions, and whether or not somatic symptoms are present. This is an areas where the members of the family are aware of the impact emotions have, and whether or not the couple or family as a whole is emotionally intelligent. Part VI: Behavioral and Action - Based Observations This area is where the patterns of interaction are described. Mostly, observable behavior and dysfunction of behavior is reported herein. Questions like “are behaviors intentional or unintended” should be mentioned. For example, one family member can exhibit behaviors reflective of being guarded, whereas another can show great composure in challenging circumstances. It could be noted the amount of time spent engaging in negative or counter - productive behaviors. Part VII: Cognitive Processes (Reason, Rationality, and Substantiated Logic) This section is available to report family members’ cognitive processes, like maladaptive thinking, ability to be rational and fair - minded, their individual retention of information, irrationality , and their lack of ability to cope with various situations. Part VIII: Test Results and Interpretation During this section, all, and I do mean all, assessment instruments are fully described. Examples are clinical mental health assessments, mental status exam, and any other battery of instruments. The number of items on each instrument, what the instrument measures, the internal consistency, the suggested time this is a test would take, the way in which the assessment was taken trends respons e selection, if the questions were true false, multiple - choice, or scaled should be included. Mention relevant raw scores, and the diagnostic range or outcomes on the assessment. Part IX: Diagnosis Considerations Here’s where you directly report the clien t’s diagnosis if appropriate and working with couples and families. For example if the client were diagnosed with a personality disorder you would state that that individual align with the diagnostic category of generalized anxiety disorder according to DS M - 5, exactly how many items of the criteria where met and then list exactly what they were. It’s significant to discuss diagnoses that were ruled out and for what reasons. Part X: Responses to Purposes and Goals of the Assessment Here is where you list o ut the original purpose and goals of the assessment and directly respond to the questions presented. For example, if the question was, th e purpose and goals of the assessment were to: 1) investigate the presence of suicidal ideation or self - harm (e.g. his tory, thoughts, feelings, plan, and means to carry out the act) then the response would be, i t has been determined through subjective and objective assessment processes, that the client is not a threat for suicide or self - harm at this time . Part XI: Limi tations and Compromising Factors During this section, limitations and compromising factors can be addressed. It can be labeled in the form of a disclaimer, particularly that the recommendations made are based on subjective and objective data collection an d interpretation processes. You may also mention ethical and best practices during this section. Finally, that the report has limited authority and may be only one piece of data presented during the case or for place of employment. There may be barriers t he couple or family presented that somehow may influence or affect the assessment process. For example, it could be resistance throughout the assessment process or trends that are evident in how responses were made on the instruments to sway the potential outcome of the results. Part XII: Cultural Considerations This section is appropriate to have because culture always plays a role in the assessment process. It could be the couple of family’s internal culture, their ethnic experiences, or perhaps the family having multiple heritages can create a medium for complex consideration. Part XIII: Recommendations for Treatment Treatment recommendations are necessary for family or couple, sometimes made to the court or agency on the behalf of the family. T his is a great section to highlight the preferences or requests made on the behalf of the family to the entity perhaps requesting the assessment. So, these recommendations could be listed as follows: w orkplace and t reatment r ecommendations ; c lient/family treatment recommendations ; Those recommendations are for the couple or family to show investment in t he i r own transformation, treatment, and healing processes necessary for adequate professional and personal relationships. Finally, there are recommendations that may come directly from the couple, parents, or family to the court or other entity, titled as c lient s tatements of p ersonal r equests . Part X IV : Future Contact or Clarification This is the last section it is great to include contact information for questions or clarification of the contents of the report. Provide name of company, address, telephone number, website information, and therapist contact information, inclusive of credentials. In closing the clinical assessment report is a comprehensive tool communicating your process and outcomes of the assessment process. It should be well - written and tailored made to the client, couple, or family. * Due Day 7 of Week 1 5 * Standards: IAMFC C1, E8, G8, h1; ACA Code of Ethics E.1.; CACREP 2.F.7; 5.F.2.o; AAMFT Code of Ethics Article 2 Section 2.1., 5.8, 6.4, 6.6; TSBEMFT §801.42, §801.46; TSBEPC §681.31, §681.43 46; TSBEPC §681.31, §681.43 Written Clinical Assessment Report (CAR) [Final Project] - 180 points Assignment #8 Rubric (Please make sure that you read each descriptions to make sure all components are met) Criteria 12.85 - 11.75 Excellent 11.74 - 10.64 Good 10.63 - 9.53 Fair 9.52 - 0 Poor Part I: Demographic Information Part II: Circumstances of Clinical Assessment Part III: Clinical Assessment Procedures Part IV: Background and Historical Information Part V: Emotional Sustainability (Stability, Maturity, Intelligence, and Regulation) Part VI : Behavioral and Action - Based Observations Part VII: Cognitive Processes (Reason, Rationality, and Substantiated Logic) Part VIII: Test Results and Interpretation Part IX: Diagnosis Considerations Part X: Responses to Purposes and Goals of the Assessment Part XI: Limitations and Compromising Factors Part XII: Cultural Considerations Part XIII: Recommendations for Treatment Part XIV: Future Contact or Clarification APA Writing and Research Requirement (Loss of Points) - 10 (no grade higher than a “B” Point Deductions from - 1 to - 9 - 0 APA criteria (research and APA manual) were followed according to course policies/syllabus for research Assignment was completely without alignment with APA criteria and had no supporting evidence. Assignment had some elements of alignment with APA criteria, but did not fully meet i t nor was assignment completely without APA research policy/criteria. APA criteria was fully met and addressed according to the research policy. *Due Day 7 of Week 15* Standards: IAMFC C1, E8, G8, h1; ACA Code of Ethics E.1.; CACREP 2.F.7; 5.F.2.o; AAMFT Code of Ethics Article 2 Section 2.1., 5.8, 6.4, 6.6; TSBEMFT §801.42, §801.46; TSBEPC §681.31, §681.43 46; TSBEPC §681.31, §681.43