Instructions: T.O is a 48-year-old Caucasian male that presents as calm and attentive. His chief complaint “I feel less unstable and have not participated in any reckless endeavors in the last 90 days”. He reports that therapy and medications are helping. T.O has a medical past history of Bipolar 1 disorder. He takes Lithium 900 mg PO every night. He denies renal complications. He also denies adverse reactions. He has no known drug allergies. He denies any surgical procedures. His weight is stable and remains unchanged. He denies difficulty with sleeping. He is a heterosexual male that has been married for 5 years. He has no children. He is alert and oriented to name, place, time, and situation. His language skills are intact. His facial expressions and demeanor reveal a relaxed mood. Affect is appropriate and congruent with mood. There are no apparent signs of hallucinations, bizarre behaviors, or other indicators of psychotic processes. He denies illicit drug use or alcohol usage. His vital signs are stable. He is well-groomed and dressed appropriately for the occasion and the season. His behavior in the session was attentive and productive with no gross and behavioral abnormalities. The plan is to continue individual CBT, add family therapy. No medication adjustment needed. Follow up appointment in two weeks.
Write a treatment plan for your client. In which you do the following:
- Describe the HPI and clinical impression for the client.
- Recommend psychopharmacologic treatments and describe specific and therapeutic end points for your psychopharmacologic agent. (This should relate to HPI and clinical impression.).
- Recommend psychotherapy choices (individual, family, and group) and specific therapeutic endpoints for your choices.
- Identify medical management needs, including primary care needs, specific to this client.
- Identify community support resources (housing, socioeconomic needs, etc.) and community agencies that are available to assist the client.
- Recommend a plan for follow-up intensity and frequency and collaboration with other providers.