Psych

Element

Excellent

1. Identifying Information

Mock name, dob, date of eval and referral source

2. Presenting Problem

A description of the client’s presenting problem, symptoms and history of pp

3. Medical/Psychiatric History

A complete description of the client’s medical and psychiatric history including possible substance abuse

4. Social/Family History

A complete description of the client’s 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