Mini Report

Validity should follow the framework of the validity assignment I have attached.
For clinical scales look at the report (graph in right) talk about one that is most elevated. 5 sentences for the
highest, 3 sentences for the next two highest.
In clinical impressions make sure to know that whatever you write will be in the hands of the patient so make
sure it is sensitive and not harsh.
Example of DIAGNOSTIC IMPRESSIONS
The following provides a summary of the Client’s diagnostic presentation as informed by the
DSM-5 and the ICD-10:
F43.10 Posttraumatic Stress Disorder
F90.2 Attention-Deficit Hyperactivity Disorder, Combined Presentation, moderate
Z62.820 Parent-biological child conflict
Z59.0 Homelessness
Give diagnoses and 3 sentences of why. Use DSM for codes.
These next three should be the first three for recommendations. Please give more as well.
They should consult with their medical provider. (make sure we rule out any medical condition there might be.
Consult with psychiatrists to see is psychopharmacology would help at this time.
They would benefit from psychotherapy. Ex CBT, Family therapy, etc Make sure to say why.
Background for the report: The patient is a 47-year-old male. He was self-referred to you in your private practice. His
wife accompanied him to the intake session where you learned that he has been unhappy for the last 9 months
(or so). He got promoted at work but the new job duties created more problems than the bump in money
provided. He feels more pressure, more responsibility, more accountability. It has affected his daily life in that
he now seems to be always working having to check emails and take phone calls on weekends and after
hours.
In addition, he is grumpy, mad, sad, and is isolating from family and friends. He is always fatigued and is putting
on weight (poor eating habits and less exercise). Finally, the change in behavior is impacting the marriage and
his wife has stated that needs to get help.

Sample Solution