Read the case study then generate a report that uses the following outline. Each section should be separated by the appropriate APA headings (Level 1, Level 2…)
Client Concerns
Symptoms Behaviors Stressors
(Examples) Sadness Trouble sleeping Parents’ divorce
Fatigue
No appetite
Hopelessness
Client Concerns: Using a table as in the example above, identify and list the client’s symptoms and any other key issues/concerns noted. (Modify the chart size as needed.) For example, these may include biological, psychological, social, and/or spiritual problems. If symptoms/behaviors overlap, you only need to list them once.
Assessment
Provide one assessment that will be used to clarify the diagnosis — a valid assessment that a counselor can use. Give a short (3-5 sentences) overview of the assessment, what it would help you learn about the client, and why you chose it over other assessments (for example: Beck Depression Inventory: identifies clinical depression, strong research base, short, easy to administer and score). Provide one peer-reviewed journal article reference to support the use of this assessment.
Diagnostic Impression
Provide the primary diagnostic impression based upon the DSM-5-TR. Include the ICD-10 code and full name of each diagnosis. Be sure to consider secondary disorders in addition to the primary disorder. Is there more than one diagnosis? Provide the following for all diagnoses.
Signs and Symptoms
List the signs (client’s report) and link them directly to the symptoms (criteria you find in the DSM-5-TR) in table form (example below) to make sure you have linked every client sign to every DSM-5-TR symptom you will use to support the diagnosis. Be sure to adjust the size of the table accordingly. If there are client reported signs that do not fall into the DSM-5-TR diagnosis, make note that you considered them, but they did not align with the DSM-5-TR.
DSM-5-TR Diagnostic Criteria: disorder name and code number Client’s Signs/Reported Symptoms:
Criterion A:
Criterion B:
Criterion C:
Criterion D:
Criterion E:
Criterion F:
Other DSM-5-TR Conditions Considered
List other DSM-5-TR conditions you considered and the process you went through to decide they were not the correct diagnosis. For example: “The client reported three symptoms of Major Depressive Disorder, but five symptoms are needed for this diagnosis, so the disorder was ruled out.”
Developmental Theories and/or Systemic Factors
Discuss theories of normal and abnormal development and/or systemic and environmental factors that affect human development, functioning, and behavior. For example, consider questions such as “What Erikson stage is the client in?” or “What is occurring within the client’s family system that may be influencing the client’s current functioning or behavior?”
Multicultural and/or Social Justice Considerations
Discuss multicultural or social justice considerations that went into your diagnostic thought process. For example, what would the client say about their symptoms/situation from their cultural point of view? Is/Could the client be experiencing concerns related to discrimination, marginalization, oppression, etc.?
Treatment Recommendations
Key Issues for Treatment
• In bullet point form, identify the top 2-3 symptoms/issues you believe are involved in the case study, in order of importance.
• The goal here is to clearly delineate what you believe will be of the most help to your client.
Recommendations for Individual Counseling
Identify two treatment recommendations for individual counseling based on the 2-3 key issues you identified.