Element
Excellent
1. Identifying Information
Mock name, dob, date of eval and referral source
2. Presenting Problem
A description of the clients presenting problem, symptoms and history of pp
3. Medical/Psychiatric History
A complete description of the clients medical and psychiatric history including possible substance abuse
4. Social/Family History
A complete description of the clients social and family history in a developmental format
5. Cultural Differences
Describes with examples cultural/religious areas that may impact treatment
6. Behavioral Observations
Completes behavioral observation based on a mental status exam, in mental health terms
Element
Excellent (4)
7. Diagnosis
Case diagnosed based on the DSM-5
8. Case Concept/Treatment Plan
Case is summarized based on the 7 elements above and future areas of treatment are identified
Total
