Describe the client’s problem areas (from the client’s perspective and any collateral source available). What are the client’s symptoms? What are issues that are interfering with the client’s functioning? How long have the symptoms occurred? After reading this section, it should be clear why the client has engaged in counseling services.
Relevant History
Please describe the information provided in the vignette in the following areas. Keep the bold headings, but delete the directions in parentheses. The information in parentheses are examples of information that could be included in each heading.
- Family and relationship history (family of origin/developmental issues, past marriages/significant relationships -duration, sexual functioning, dissolution factors, sexual orientation, etc., children -from current or prior relationships and current status, current family status and structure)
- Cultural history and identity (issues of ethnicity and race, identification/acculturation)
- Educational history (childhood/developmental, adulthood/current status)
- Vocational history (types, stability, satisfaction)
- Medical history (acute/chronic illness, hospitalizations, surgeries, major patterns of illness in family, accidents, injuries, with whom/where/how often receive medical care, etc.)
- Health practices (sleeping, eating patterns, use of tobacco, consumption of caffeine etc)
- Mental health history (prior problems, symptoms, diagnoses, evaluations, therapy experiences, past prescribed medications, current and family of origin mental health histories)
- Suicide/self-harm history (prior suicidal or non-suicidal self-harm behavior thoughts and/or attempts and/or interventions)
- Current medications (dosages, purposes, physician, compliance, effects, side effects, etc) – if the client is not currently taking medications, describe the medications that are likely to be prescribed based on the client’s symptoms/diagnoses
- Legal history/status (arrests, DUI, jail/prison, lawsuits, any pending legal actions; include custodial status when appropriate)
- Use/abuse of alcohol or drugs (prescription or illegal)
- Family (current and origin) health/alcohol/drug history
Formal Diagnosis
What is the client’s full diagnosis? Include all DSM-5-TR diagnoses. Include the code number, clinical diagnosis, subtype, and specifiers. Do not include additional information.
Diagnostic Rationale
Describe the client’s specific symptoms which led to a decision for the diagnoses given above. Do not describe the symptoms straight from the DSM-5, but refer to the criteria enough to where the reader does not need a DSM-5 to follow along. For example, if the client is having hallucinations, describe how you know the symptom of hallucination is met.
Differential Diagnosis
What other diagnoses were considered while determining the diagnosis for this client? Why? How were those diagnoses “ruled out?” Include the specific criteria which ruled out the diagnosis.
Neurological and Biological Considerations, including Psychopharmacology
This section contains a summary of your understanding of the neurological components of the disorder(s) you diagnosed and what types of medications that you might expect a physician to diagnose (and why you think that). Also discuss the possible benefits and side effects of this medication.
