The document outlines the process for conducting a comprehensive counseling assessment that includes client background, the rationale for seeking help, and biopsychosocial factors. It emphasizes the importance of identifying symptoms, environmental influences, cultural identity, co-occurring disorders, and addiction assessments to formulate effective recommendations for recovery and relapse prevention. The structure serves as a guideline for creating detailed DAP notes for clinical documentation.

1. Description I. Introduction A. Summarize the client. What is the
rationale for seeking counseling?
II. Biopsychosocial Summary
A. Describe the problem that brought the client to treatment. i.
Make sure to address any problems, issues, or challenges the
client may be facing.
B. Explain the symptoms affecting the client. i. What are the
behavioral symptoms? ii. What are the cognitive symptoms? iii.
What are the emotional symptoms? iv. What are the
physiological symptoms?
C. Identify any environmental factors that may be contributing
to the client's problem.
D. Identify any potential harmful behavior: i. Aggression ii.
Harm to others iii. Harm to self iv. Criminal activity v.
Impulsive behaviors vi. High-risk activity
E. Determine if the client has a family history of the diagnosis.
Consider how this may affect the client. F. Use evidence-based
research to support the biological factors presented in the case.
G. Outline how the client identifies him- or herself in regard to
cultural characteristics. Make sure to add rationale for any
answers that are not straightforward. i. What are the addressing
factors?
a. Age and generational influences
b. Developmental disabilities (acquired at birth or during
childhood)

2. c. Disabilities acquired later in life (e.g., traumatic brain injury,
multiple sclerosis, stroke)
d. Religion and spirituality
e. Ethnic and racial identity
f. Socioeconomic status
g. Sexual orientation
h. Indigenous heritage
i. National origin j. Gender
H. Summarize how the client culturally identifies him- or
herself.
i. With the identifiers above, how does the client culturally
identify him- or herself? ii. What is the order of importance for
the client? Assessment III. Co-occurring Disorders
A. Identify any co-occurring disorders. B. Describe the initial
DSM diagnosis. i. What is the overall descriptor of the
diagnosis? ii. What criteria must be met to meet the diagnosis?
iii. Describe which client behaviors are being used to meet the
diagnostic criteria.
C. Discuss the rationale behind the diagnosis. i. Identify what
other diagnoses should be ruled out. Make sure to provide
rationale. ii. Identify limitations with this diagnosis. Make sure
to provide rationale.
D. Use evidence-based research to support your justification.
IV. Addiction Assessments

3. A. Describe how the assessment was administered.
B. Describe the assessment scoring.
C. Summarize the assessment results.
i. How do you interpret the results? Plan V. Recommendations
A. Summarize what you recommend for this client based on the
information collected.
i. Describe what you recommend for recovery.
ii. Describe what you recommend for relapse prevention.
resources you would provide to the client. Rubric Guidelines
for Submission: Consider using the headings from the critical
elements outlined above when drafting your DAP note, as you
will do this when you submit for your final project. You may
also consider using double spacing, 12-point Times New Roman
font, and one-inch margins, although none of these
specifications are required for the draft version. Critical
Elements Pro