Please use the following outline. Demographic Information: Age Sex Race/Ethnicity Culture Religion Marital/Relationship status Any other pertinent information, but keep this section somewhat short and to-the-point. You will elaborate later. Current Problems/Presenting Problems: Provide a thorough account of the reason client came to see you and/or was brought to you by friends/family. Detail will help here (but do not do a plot summary). Problematic symptoms Frequency of symptoms (how often do they occur?) Duration of symptoms (how long have they been present? Severity of symptoms (how serious are they?) Symptom triggers (do certain events or situations seem to trigger the symptoms Social and Occupational History: Information on family of origin including ethnic/cultural information – where did client grow up? Who did client live with? Were parents married/separated/estranged? Any siblings? Strong ties with Grandparents? Etc. General information on childhood Traumatic events History of abuse Notable events Occupational history Current employment Past employment Employment struggles/successes Educational history Highest level of education achieved Educational struggles/successes Current family constellation General information on spouse/partner (remember to focus on your client’s symptoms, you are only diagnosing one person; report whatever you think may be impacting your client) General information on children and close family members Is client satisfied with current family situation? Psychiatric History Provide history of mental health diagnoses prior to when you met the client as well as any treatment received Include a family history of psychiatric conditions in this section (if no history state that there is no family history Medical History Note all medical conditions the client has (these are conditions that are not psychiatric in nature, such as diabetes) Especially for conditions that might impact mental functioning, provide details about treatment, prognosis, etc. For example, is the client managing their diabetes well? Diagnostic Summary First, summarize the information you obtained in your report in 1-2 paragraphs (hint: focus on what most directly connects to your diagnosis Explain each diagnosis you made and why Specifically list which criteria from the DSM the client meets Explain any other diagnoses you considered and explain why you ultimately ruled them out Provide a brief prognosis – is this treatable? Will the client have a good quality of life? Provide a brief treatment plan What type of therapy would be beneficial? Would you refer this client to a psychiatrist for medication? Does this client need to be hospitalized immediately?
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