Describe any symptoms or behaviors that are inconsistent with the diagnosis.

Briefly outline the client’s background (age, race, occupations, etc.).
• Describe any factors in the client’s background that might predispose him or her to this disorder.
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 the 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?
Writing
• Write in a clear, concise, and organized manner; demonstrate ethical scholarship in the accurate representation and attribution of sources; and display accurate spelling, grammar, and punctuation.

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