1. Introduction of the client: A brief paragraph stating the demographic information and the presenting problems that led the client to treatment, as well as how the client came in (mandated, self, family).
2. DSM-5-TR Diagnosis that outlines the specific criteria met and provide a strong rationale for the selected diagnosis. The client may have more than one principal diagnosis, and don’t forget the specifiers and the Z Codes. Use the most current codes in parenthesis.
3. Differential Diagnoses: The process of weighing the probability of one disorder versus that of other disorder possibly accounting for a client’s illness. Be sure to list all relevant possible diagnoses. Use DSM-5-TR specific language to provide a rationale for why you considered a particular diagnosis and, subsequently, what allowed you to rule this diagnosis out at this time.
4. Brief conceptualization of the client: What hypotheses do you have about this person? Include strengths, challenges, and cultural implications. Think holistically and consider the biological, psychological, social, and spiritual issues. What is the person’s story?
5. Suggested Treatment Care Recommendations:
a. Crisis needs. Be sure to take into consideration the need for a suicide/homicide assessment; the need for hospitalization; the need for an immediate medical evaluation.
b. Case Management and Referral Needs such as housing, funding, vocational assistance, respite care services, referral to a psychiatrist, or medical doctor.
c. Type of Therapy/Treatment Recommended. Examples: medications, individual, psychosocial rehabilitation, group, family, vocational. What is the evidenced based recommendations as well as individual creative possible interventions?
d. Prognosis. What is the likely course of the illness? Will the client likely get better or will this be a chronic disorder that will require ongoing intervention?
6. Self-Reflection: What issues might you have working with the client and what issues might the client have with you?
7. Medications:
a. What type of medication(s) might be recommended for the client? (not specific but general category).
b. What side effects might these medications cause?
c. What counseling advice related to medication would you need to provide?
**EXAMPLE IS PROVIDED (JOHN)**