There are parts to the case conceptualization 1. Evaluation & Assessment- identify precipitating problems/symptoms,provide a comprehensive biopsychoscial assessment/history, Identify indivdual & relationship functioning 2. Case Conceptualization- Diagnosis & Treatment Planning,Integrate client assessment & observational data to form a conceptualization, Utilize clinical judgment,formulate a differential diagnosis, Develop a treatment plan. 3.Clinical Practice-Determine & identify other services that could meet the client's needs, identify and discuss applicable ethical and legal issues,Discuss the scope of practice parameters and any foreseen limitations. APA format. Paper #1 Outline A. Presenting Problems/Symptoms Include here a thumbnail sketch of the client.  Presenting problems are what brings them to therapy; who referred them; why?  What is their understanding of the problem?  Symptoms are terms used by clinicians to arrive at a diagnosis.  Include a statement about Suicidal and Homicidal ideation .  B. Comprehensive psychosocial assessment/history 1. Family history Who is in their immediate family? What are the family dynamics? 2. Current living situation Where do they live? Who do they live with? Have there been changes in living arrangements recently? 3. Health Client’s health history as well as significant health issues in the family 4. Education/Employment Relevant educational and employment information 5. Spirituality Relevant cultural and spiritual context and issues 6. Legal Current and past legal issues; including probation; divorce or custody issues 7. Mental Health Include mental status exam results; suicidal/homicidal ideation; previous diagnoses, treatments; family history of mental health 8. Substance Abuse Include previous diagnoses of substance abuse; previous treatment attempts; age of first use; amount of last use; frequency of use; drugs of choice; family history of substance abuse 9. Violence Own history of violent behavior and family history of violence 10. Individual and relationship functioning* The individual’s level of functioning as well as a description of their significant relationships and their ability to maintain those relationships.  Include information about their interpersonal relationships as well as their intra-personal functioning. 11. Strengths/Limitations Not only what the client reports, but what you observe about the client; what about social strengths?  This is really an opportunity for a summary paragraph. C. Any assessment scores or measurement tools Not necessary but if you use any instruments this is when you would report it. II. Diagnosis and Treatment Planning A. Integrated client assessment and observational data to form a conceptualization Two paragraphs here…  First, give an explanation of the client’s problem in keeping with their psychosocial history using your theoretical orientation.  Second, justify your diagnosis based on the client’s problems and symptoms, .

1. There are parts to the case conceptualization
1. Evaluation & Assessment- identify precipitating
problems/symptoms,provide a comprehensive biopsychoscial
assessment/history, Identify indivdual & relationship
functioning
2. Case Conceptualization- Diagnosis & Treatment
Planning,Integrate client assessment & observational data to
form a conceptualization, Utilize clinical judgment,formulate a
differential diagnosis, Develop a treatment plan.
3.Clinical Practice-Determine & identify other services that
could meet the client's needs, identify and discuss applicable
ethical and legal issues,Discuss the scope of practice parameters
and any foreseen limitations. APA format.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.

2. Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence

3. Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.

4. Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.

5. Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.

6. C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history

7. 1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse

8. Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial

9. history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family

10. 4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.

11. 11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a

12. statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.

13. Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.

14. Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been

15. changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.

16. Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.

17. Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.

18. Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools

19. Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history

20. Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance

21. abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic

22. of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment

23. Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations

24. Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.

25. B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health

26. 8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization

27. Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.

28. Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of

29. their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting

30. problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or

31. custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.

32. Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.

33. Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.

34. Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.

35. Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.

36. Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.

37. C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history

38. 1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse

39. Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial

40. history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family

41. 4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.

42. 11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a

43. statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.

44. Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.

45. Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been

46. changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.

47. Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.

48. Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.

49. Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools

50. Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history

51. Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance

52. abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic

53. of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment

54. Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations

55. Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.

56. B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health

57. 8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization

58. Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.

59. Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of

60. their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting

61. problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or

62. custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.

63. Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.

64. Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.

65. Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.

66. Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.

67. Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.

68. C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history

69. 1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse

70. Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial

71. history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family

72. 4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.

73. 11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a

74. statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.

75. Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.

76. Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been

77. changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.

78. Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.

79. Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.

80. Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools

81. Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history

82. Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance

83. abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic

84. of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment

85. Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations

86. Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.

87. B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health

88. 8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization

89. Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.

90. Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of

91. their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting

92. problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or

93. custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.

94. Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.

95. Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.

96. Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.

97. Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.

98. Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.

99. C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history

100. 1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse

101. Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.
11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial

102. history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a
statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family

103. 4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.
Mental Health
Include mental status exam results; suicidal/homicidal ideation;
previous diagnoses, treatments; family history of mental health
8.
Substance Abuse
Include previous diagnoses of substance abuse; previous
treatment attempts; age of first use; amount of last use;
frequency of use; drugs of choice; family history of substance
abuse
9.
Violence
Own history of violent behavior and family history of violence
10.
Individual and relationship functioning*
The individual’s level of functioning as well as a description of
their significant relationships and their ability to maintain those
relationships. Include information about their interpersonal
relationships as well as their intra-personal functioning.

104. 11.
Strengths/Limitations
Not only what the client reports, but what you observe about the
client; what about social strengths? This is really an
opportunity for a summary paragraph.
C.
Any assessment scores or measurement tools
Not necessary but if you use any instruments this is when you
would report it.
II.
Diagnosis and Treatment Planning
A.
Integrated client assessment and observational data to form a
conceptualization
Two paragraphs here… First, give an
explanation
of the client’s problem in keeping with their psychosocial
history using your theoretical orientation. Second,
justify your diagnosis
based on the client’s problems and symptoms, include the logic
of your reasoning to arrive at this diagnosis and not another.
This is the more academic aspect of your paper.
Paper #1 Outline
A.
Presenting Problems/Symptoms
Include here a thumbnail sketch of the client. Presenting
problems are what brings them to therapy; who referred them;
why? What is their understanding of the problem? Symptoms
are terms used by clinicians to arrive at a diagnosis. Include a

105. statement about
Suicidal and Homicidal ideation
.
B.
Comprehensive psychosocial assessment/history
1.
Family history
Who is in their immediate family? What are the family
dynamics?
2.
Current living situation
Where do they live? Who do they live with? Have there been
changes in living arrangements recently?
3.
Health
Client’s health history as well as significant health issues in the
family
4.
Education/Employment
Relevant educational and employment information
5.
Spirituality
Relevant cultural and spiritual context and issues
6.
Legal
Current and past legal issues; including probation; divorce or
custody issues
7.