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Provide relevant case information as indicated in the spaces below. The material presented can be inspired by past or current field or professional involvement, however, all identifying information must be omitted to guarantee the anonymity of your subject(s). Cases will be selected for use in the course assignment based on:
1) clarity of the information presented,
2) ethnic/racial/developmental diversity across cases, and
3) potential for varying applications of evaluative methods and designs.
4) Client must have 3 diagnosis / 2 Subjective and 1 Objective
IDENTIFYING INFORMATION (fictitious): Client(s)’ name, age, gender, ethnicity, socioeconomic status, occupation.
CHIEF COMPLAINT: Quote of response to “What would you consider the main problem or problems you would like help with?”
HISTORY OF CURRENT PROBLEM: Duration of the problem (i.e. beginning when?), precipitating or concurrent events (if any), previous attempts at treatment (and results, if relevant).
FAMILY MENTAL HEALTH HISTORY: Have other family members sought help for similar or related problems? Specify.
BACKGROUND INFORMATION: Relevant history of the problem, including pertinent individual and family developmental material, occupational/school events, physical health, history of abuse or neglect (emotional, physical, sexual), substance abuse.
MENTAL STATUS EVALUATION: Here, you may recall your initial meeting with the client, or “make-up” the client(s)’ presenting condition to facilitate the class assignment. Describe the client(s)’ appearance, behavior, mood/affect, clarity of thought, and capacity for insight, and clear judgment based on your initial assessment.
DIAGNOSTIC SUMMARY: Briefly stated, your initial assessment of the client(s)’ problems/needs, providing potential DSM-5 diagnosis.