Mental Health Assessment and Case Formulation

Assessment 2: 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.

Assessment 3

Collaborative Care Plan

Instructions and Overview

Purpose:
The purpose of this task is for the student to demonstrate how to create a holistic plan of care that is person-centred, trauma-informed, and recovery-oriented in focus.

Description:
In this written assignment, you are required to prepare a holistic and collaborative care plan that addresses the care and recovery needs of the consumer that you identified in Assessment 2.

Your plan of care should:

• Describe the current context of care (e.g. healthcare setting; type of admission; legal status)
• Outline the consumers goals for recovery and future plans
• Outline the consumers strengths and resources for recovery (e.g. skills, support)
• Identify priorities for safety, care and recovery for the consumer
• Identify strategies and interventions which could be utilised to address and support each of the priorities you have identified.

In your writing, you must provide evidence which shows that you used a collaborative approach that is consumer focused, and recovery orientated. You must provide evidence from current high-quality evidence based literature to support your approach, the strategies and the interventions that you outlined in the collaborative care plan.

Format:
Please format your submission as outlined in the Course Outline.

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

• Introduction
• Current Context of Care
• Consumer Goals for Recovery & Future Plans
• Consumer Strengths and Resources for Recovery
• Priorities for Safety, Care & Recovery
• Strategies & Interventions to Support Priorities for Care, Safety & Recovery
• Conclusion

Summary of Assessment Requirements

Assessment 2: Case Formulation

Students were required to undertake a holistic mental health assessment of a consumer (aged 12–24) from an inpatient or community mental health setting. The case formulation needed to:

• Provide an introduction to the consumer (using a pseudonym) and explain reasons for their presentation.
• Present a comprehensive biopsychosocial history.
• Conduct a structured Mental State Examination (MSE).
• Undertake a comprehensive risk assessment, including adaptive coping strategies.
• Develop a structured case formulation using a recognised tool.

Assessment 3: Collaborative Care Plan

Building on Assessment 2, students were asked to prepare a holistic, person-centred, trauma-informed, and recovery-oriented care plan for the same consumer. The plan had to:

• Describe the current context of care (setting, admission type, legal status).
• Outline the consumer’s goals for recovery and future plans.
• Identify the consumer’s strengths and resources that support recovery.
• Highlight priorities for safety, care, and recovery.
• Propose strategies and interventions to address these priorities, supported by evidence-based literature.
• Demonstrate a collaborative and consumer-focused approach.

Step-by-Step Approach by the Academic Mentor

The academic mentor guided the student through the tasks systematically:

1. Understanding the Purpose of the Assessments
   The mentor first explained that Assessment 2 (Case Formulation) was about understanding the consumer’s condition holistically, while Assessment 3 (Collaborative Care Plan) was about designing practical, recovery-focused interventions.

2. Structuring the Case Formulation (Assessment 2)

   • Introduction: The mentor guided the student to present the consumer using a pseudonym and briefly outline presenting issues.

   • Biopsychosocial History: The student was advised to gather details about biological, psychological, and social factors influencing the consumer’s condition.

   • Mental State Examination (MSE): The mentor explained how to systematically assess appearance, mood, thought processes, cognition, and perception.

   • Risk Assessment: The student was coached on identifying potential risks (self-harm, harm to others, neglect) while also noting coping mechanisms.

   • Case Formulation: Using a recognised tool, the mentor helped the student link history, risks, and symptoms into a logical structured analysis of the consumer’s condition.

3. Developing the Collaborative Care Plan (Assessment 3)

   • Current Context of Care: The mentor guided the student to describe the clinical setting, type of admission, and legal aspects.

   • Consumer Goals: The student was encouraged to capture the consumer’s personal recovery goals in their own words.

   • Strengths & Resources: The mentor emphasized focusing on positive aspects such as skills, social support, and coping strategies.

   • Priorities for Safety & Recovery: The student was supported in identifying immediate safety needs and long-term recovery priorities.

   • Strategies & Interventions: The mentor guided the integration of evidence-based interventions, ensuring each strategy was directly linked to identified priorities and supported by literature.

   • Collaborative Approach: The student was reminded to highlight consumer involvement in decision-making to reflect a person-centred and recovery-oriented approach.

Outcome and Learning Objectives Achieved

By the end of the assessments, the student had:

• Demonstrated the ability to conduct a holistic mental health assessment using a structured approach.
• Practiced formulating a case that integrates biopsychosocial, clinical, and risk factors.
• Learned how to develop a collaborative, trauma-informed care plan that is grounded in evidence-based practice.
• Shown understanding of how to balance clinical priorities with consumer goals for recovery.
• Strengthened academic skills in structuring assignments, integrating literature, and maintaining confidentiality with professional integrity.

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