Provide a brief summary of      what you have learned about the individual reviewed in the case. Include information about the individual      in terms of demographics and general history, and the sources of that      information, and the reason that the individual was referred, and by whom.  

1. Case Summary

• Provide a brief summary of      what you have learned about the individual reviewed in the case. Include information about the individual      in terms of demographics and general history, and the sources of that      information, and the reason that the individual was referred, and by whom.
• Summarize any information      you may have about evaluations that have been conducted, including the      results.

2. Clinical Impression (Diagnosis)

Write the clinical impression in the DSM-5 format:

XXX.xx (Yyy.yy) Primary Diagnoses (list in order of salience).

(DSM-5 Code is first, as in XXX.xx, and ICD-10 codes next, in parentheses.)

OTHER FACTORS:

Use the V and Z codes, or simply appropriate descriptors to psychosocial and contextual factors of importance to the diagnostic case. These replace the DSM-IV-TR Axis IV & V used to address these concerns.

3. Recommendations

Explain any recommendations for interventions, treatment, and/or disposition.

4. Questions

Address the specific questions that were asked in the instructions for this assignment.

Here is a sample assignment question and an appropriate brief response:

Question: Describe what further information you would need to accurately diagnose this case.

The Case of Kristopher

Kristopher is a 14-year-old boy who was recently accused by a female classmate of forcing her to have sex with him. He claimed that she agreed to have sex with him and then became angry because he went out with other girls. Kristopher is known as a bully and often fights with other students. He was removed from his biological mother’s home when he was 4-years-old because she was unresponsive when he was repeatedly abused by her boyfriend. Kristopher was adopted by his current parents when he was 7-years-old after he had lived in a series of foster homes. He was a known charmer. Despite his charm, however, he had difficulty controlling his temper and seemed to take pleasure in being cruel to other children and animals.

During the next few years, Kristopher’s adoptive parents tried to help him. They worked with the school to help him control his temper and provided him with therapy. However, his behavior became increasingly difficult to manage. He frequently lied and sometimes stole money from his mother. He began to spend time with other adolescents who were known to use drugs. His school performance, which had never been satisfactory, deteriorated even further. Soon after he was accused of the sexual assault, he ran away from home but was caught by police and arrested.