Self Esteem Disturbance

 

Instructions: Fill out this form, print it, and hand it in with your assessment to your instructor. When you click on Next at the bottom of the page, you see the data you submitted. Please follow the instructions on how to save the data on the next page.

AOL users: Read this instruction.

Definition: negative self evaluation/feelings about self or self-capabilities

1. Your initials (required): 

2. Defining Characteristics- check those that apply to your client:

None- high risk diagnosis  expressions of shame or guilt self-negating verbalization rejects positive feedback
exaggerates negative feedback hesitant to try new things hypersensitivity to criticism
3. Related Factors- check those that apply to your client:

assumption of new role chronic illness chronic pain situational crisis failure at work or in school
hospitalization or institutionalization  pschologic impairment unmet expectations for childbirth or child
history of abusive relationships


4. Goal (ultimate, long term) 

5. Outcome Criteria (short term) 

6. Evaluation: Was the outcome criteria met? 

Yes- Give Evidence: 

No- Explain how you would change the plan: 

7A. Interventions 

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7B. Rationale for each intervention
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