Diagnostic Assessment

Jan Williams needs for mental health services became more apparent, she could no longer overlook the need for services. She looked through the yellow pages of the phone book at the various providers and found a company by the name of St. Mary’s Home Care Agency, Inc. that provided an array of services, one to include Outpatient Mental Health services. She called the number and requested help for her special needs, because she was hearing voices and her mood swings were horrible. To start the process the secretary forwarded her call to the Intake Specialist, who in turn asked her some personal questions for the referral process. Some of the answers included her name, date of birth, address, telephone number and an emergency contact number.
First, the Intake Specialist asked Jan to let her know what her major complaint was, which would let her know how to forward her case on the next professional. Jan explained to her that she was hearing voices and had terrible mood swings that she could not control at times. The Intake Specialist then stated that she would forward Jan’s referral to the Qualified Professional who would complete a screening, which would be the second step in obtaining Mental Health services.
Her date for the screening process was scheduled for the next week. Upon arrival to St. Mary’s Home Care Agency, Inc. a nice lady addressed Jan and said, “Ms. Williams please follow me”. Next we entered into a private room and the Qualified Professional began to ask me a series of questions, which included my habits, education, substance abuse use, mental and physical health and family background. Jan answered all the questions to the best of her ability and the Qualified Professional completed the screening process. After the screening process she instructed Jan that the next step would be to forward the screening to the Psychiatrist on staff and set up an appointment for her to get a Diagnostic Assessment, which is an assessment that tells persons cognitive level of functioning. The result of the Diagnostic Assessment would tell what Jan’s Axis Codes are and any recommendations of medications and further testing that may be required. The Diagnostic Assessment was completed by the Psychiatrist on staff a week after Jan’s initial screening. During the Diagnostic Assessment it was concluded that Jan has an Axis 1 of Bipolar, PTSD, an Axis II of Borderline Traits, an Axis III of obesity, HTN, high cholesterol, chronic back pain, an Axis IV of limited social supports, legal problems and no documented Axis V. Jan’s GAF score, which is her current level of
functioning, is 45. The Psychiatrist recommended that she be placed on Community Support Team, which is a service that provides outpatient assistance with Activities of Daily Living and social supports. He also recommends that Jan see a Family Therapist because she is lacking family support. After that Jan was introduced to the Qualified Professional that will be in charge of her case and will prepare a Person Centered Plan (PCP), which is a plan of care that has individualized goals for Jan to reach and includes a crisis prevention/response plan. The Qualified Professional also included in the Person Centered Plan all the recommendations documented by the Psychiatrist. The Associate Professional and Paraprofessional will also collaborate with the Qualified Professional and Jan on a weekly basis to assist her with completing goals, helping with activities of daily living and socialization skills. Finally after her services started the “team”, (Qualified Professional, Associate Professional and the paraprofessional), were extremely helpful and worked well together. The services included Jan speaking with other professionals, such as therapists and psychologists. Hearing voices became less and the mood swings were controllable. Jan was able to get on the right medications because of the Community Support team and the Psychiatrist. Jan has been stable and able to be in the community without having any episodes that she could not handle. Currently she still keeps her therapy appointments and visit the Psychiatrist on a monthly basis, unless an emergency arises, which would mean she visits the Psychiatrist more frequently.