1. Adapted from Morrison & Flegel (2016), Chapter 10
2. Written Report
2.1. Identifying Data
2.1.1. Note the client's demographic information and any previous treatment episodes.
2.2. Chief Complaint
2.2.1. Cite the client's stated reason for entering treatment.
2.3. History of Present Illnesses
2.3.1. Assess the client's timeline of symptoms and stressors to obtain their chronological account that motivates their reason for seeking treatment.
2.4. Personal & Social Background
2.4.1. Address whether developmental milestones have been met and additional pertinent individualized information related to a client's functionality in social contexts.
2.5. Family History
2.5.1. Identify whether hereditary influences are present and how temperament of immediate family members may affect symptom presentation of client.
2.6. Medical History
2.6.1. Rule out possible medical conditions that can demonstrate similar symptoms through addressing immunizations, childhood diseases, major illnesses, operations, hospitalizations, medications, etc.
2.7. Mental Status Exam (MSE)
2.7.1. Evaluate client's overall functionality in terms of how they present (appearance), how they convey their concerns (speech and language), what their emotional state is (mood and affect), and how they demonstrate competency in their present orientation (attention, motor activity, sensory capabilities, thought process, etc.).
3. Case Formulation
3.1. Brief Restatement
3.1.1. Provide summary of identifying data, pertinent MSE information, and chronological information that contribute to and explain current symptoms.
3.2. Differential Diagnosis
3.2.1. Address possible diagnoses that may be present as a result of the client's symptoms and background, and provide rationale for reasons for and against each of these diagnoses.
3.3. Best Diagnosis
3.3.1. State what is the most likely diagnosis underlying client's current behavior.
3.4. Contributing Factors
3.4.1. Review how hereditary and environmental factors contribute to the chief complaint, as well as various other biopsychosocial factors. It is also important to recognize client strengths in this section.
3.5. Additional Information Needed
3.5.1. Identify what supplemental materials will be beneficial to support the diagnosis.
3.6. Treatment Plan
3.6.1. Create an outline for personalized treatment in accordance with the client's biopsychosocial needs and recognition of barriers.
3.7. Prognosis
3.7.1. Hypothesize the likely outcome of the suggested course of treatment for the client.