Order Description
Observations
Describe any symptoms that you have observed that support the diagnosis. You can include direct quotes or behaviors that you may have observed.
Describe any symptoms or behaviors that are inconsistent with the diagnosis.
Provide any information that you have about the development of this disorder.
Diagnosis
Did you observe any evidence of general medical conditions that might contribute to the development of this disorder?
Did you observe any evidence of psychosocial and environmental problems that might contribute to this disorder?
As per your observations, what is the client’s overall level of safety regarding potential harm to self or others (suicidality or homicidality)?
What cross-cultural issues, if any, affect the differential diagnosis?
Therapeutic Intervention
In your opinion, what are the appropriate short-term goals of this intervention?
In your opinion, what are the appropriate long-term goals of this intervention?
Which therapeutic strategy seems the most appropriate in this case? Why?
Which therapeutic modality seems the most appropriate in this case? Why?