Case Study

EVALUATOR:

DATE OF EVALUATION/CLINICAL INTERVIEW:

A. Identifying Information:

Name:

DOB

Age:

Race:

Other Identifying Information:

B. Chief Complaint/Reason for Referral:

C. History of Present Illness:

D. Psychiatric History:

E. Personal and Social History:

F. Medical History:

G. Mental Status Check:

H. DSM IV Diagnoses:

Axis I:

Rule Out:

Axis II:

Axis III:

Axis IV:

Axis V:

I. Diagnostic Rationale:

J. Differential Diagnosis:

K. TREATMENT PLAN:

A. Treatment Goals:

B. Treatment Recommendations/Interventions

C. Prognosis/Obstacles: