Formal Diagnosis
DSM-5 Diagnosis, ICD-10 Code, Specifiers and include at least 1 (one) differential
diagnosis.
Diagnostic Rationale
Discussion of symptoms/criteria showing how client meets the diagnostic criteria for the
diagnoses given above. Include the differential diagnoses, demonstrating you ruled out
other diagnoses.
Theoretical Conceptualization of the Case
First, identify the specific theory or theories used and provide a brief overview of the
general theory’s main points. Next, describe how the conceptualization was then applied
to understand the existence of this particular client’s problems. Finally, describe how the
conceptualization affected the therapist’s approach to treatment, which may also include
discussion related to multicultural variables.
Recommendations
Each of the following are required to be included in your recommendations:
• Prognosis.
• Should services continue to be offered, or would a referral for counseling services
elsewhere be more appropriate?
• Potential referral(s) to other professions (e.g., medical, psychiatric, etc.).
• Recommendation for a specific therapeutic orientation to be used with this client.
• Nature of treatment (e.g., specific therapist, priority of treatment issues, interaction
with client characteristics such as defensiveness, motivation for treatment, problem
complexity, etc.).
• Format recommendations concerning working with the client (e.g., individual, group
therapy, etc.).
0 comments