Assessment 2: Mental Health Assessment and Case Formulation

Instructions and Overview

Purpose:

The purpose of this assessment task is for students to demonstrate their ability to undertake a holistic mental health assessment and engage case formulation based on a consumer from the youth and young adult age demographic (12–24 years).

Description:

In this assessment task your mental health assessment must be based on a consumer that you have cared for within the context of an inpatient setting or community-based mental health service.

You are required to undertake a holistic mental health assessment and provide a structured formulation using a recognised formulation tool. In order to maintain confidentiality in your final submission, you must use a pseudonym when referring to this consumer and the context in which the mental health assessment was based. In other words, do not give the real name of the consumer or the clinical area that you work in.

Your case formulation should:

• Provide an introduction to the consumer and give an overview of the reasons why they are presenting to the inpatient setting or community mental health service

• Present a comprehensive biopsychosocial history

• Provide a comprehensive and structured mental state examination

• Present a comprehensive risk assessment which includes adaptive coping strategies

• Provide a structured formulation of the persons presentation

As you are completing this mental health assessment with a young person, your assessment and formulation needs to acknowledge key factors that are relevant to their age group – 12–24 years. You need to incorporate specific assessment tools or evidence-based strategies that are used in the assessment and case formulation of consumers from this demographic.

Format:

Please format your submission as outlined in this Course Outline.

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For this task you are encouraged to use the following subheadings to structure your written assessment:

• Introduction to the consumer

• Overview of the presenting problems

• Biopsychosocial history

• Structured Mental State Examination

• Risk Assessment & Adaptive Coping Strategies

• Structured Formulation of the Consumer’s Presentation

• Conclusion

Please do not use tables, graphs, point form or bullet points to present your work.

Although the focus of this written assessment is the completion of a mental health assessment, you must use a scholarly approach and use relevant evidence based literature in support of your assignment.

NOTE: This assessment will be the basis for your collaborative care plan that will be developed for Assessment Task 3.

Compulsory: Submit assessment item – You must submit this assessment to pass the Course.

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1. Assessment Requirements – Summary

Students are required to complete a written assessment (1500 words) focused on conducting a holistic mental health assessment and case formulation for a consumer in the youth and young adult demographic (12–24 years).

Key Pointers to be Covered:

• Introduction to the consumer and their presenting issues

• Comprehensive biopsychosocial history

• Structured Mental State Examination (MSE)

• Risk assessment and adaptive coping strategies

• Structured formulation of the consumer’s presentation

• Conclusion summarising findings and implications

Additional requirements:

• Use pseudonyms (no real names).

• Apply evidence-based strategies relevant to the 12–24 age group.

• No tables, graphs, or bullet points – must be in scholarly narrative style.

• Must follow course outline formatting.

• Final submission is compulsory (no reattempts permitted).

Step Approach by Academic Mentor

Step 1: Clarifying Purpose and Scope
The mentor began by helping the student understand that the task requires integration of theory and practice, with focus on a holistic view that includes biological, psychological, and social factors.

2: Structuring the Assessment
The mentor recommended the use of the suggested subheadings: Introduction, Presenting Problems, Biopsychosocial History, Mental State Examination, Risk Assessment, Case Formulation, and Conclusion.

3: Writing the Introduction
The student was advised to start with a pseudonym for the consumer, their demographic details (age, background), and reasons for accessing inpatient or community-based mental health services.

4: Developing the Biopsychosocial History
Guidance was given on including medical conditions, social environment, family dynamics, education/employment background, cultural influences, and psychological history.

5: Conducting the Mental State Examination (MSE)
The mentor emphasized that the MSE should cover appearance, behaviour, speech, mood and affect, thought processes, perception, cognition, and insight. Each observation should be supported with relevant literature.

6: Performing Risk Assessment and Identifying Coping Strategies
The mentor instructed the student to consider risks such as self-harm, substance misuse, or social vulnerabilities, as well as coping mechanisms like family support, therapy, or community activities.

Step 7: Formulating the Consumer’s Presentation
The student was encouraged to use a recognised framework such as the “5 Ps” model (Presenting, Predisposing, Precipitating, Perpetuating, and Protective factors). This ensures a structured and professional explanation of the case.

8: Academic Writing Style
The mentor highlighted that writing must remain in paragraph form with scholarly tone and supported by evidence-based literature. Bullet points and graphs are not permitted.

9: Writing the Conclusion and Linking to Task 3
Finally, the mentor guided the student to prepare a conclusion that summarises the case assessment and prepares the foundation for the next assessment task – the collaborative care plan.

Final Outcome and Learning Objectives Achieved

Outcome:
The student successfully produced a well-structured, evidence-based mental health case formulation with attention to confidentiality, professional writing, and integration of theory into practice.

Learning Objectives Covered:

• Ability to conduct a holistic assessment of young people (12–24 years)

• Application of evidence-based strategies in case formulation

• Systematic completion of a Mental State Examination

• Competence in risk assessment and identification of coping strategies

• Academic writing skills in presenting structured case formulations

• Preparation for collaborative care planning (Assessment Task 3)

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