CLINICAL ASSESSMENT REPORT

CLINICAL ASSESSMENT REPORT

(Confidential)

(Do Not Copy Without Written Permission)

Directions: View the directions for this assignment in the content folder in Blackboard. When it is time to complete this document, do so as if it is documentation that would go into a client’s file. Do NOT use APA style. Do NOT cite any sources – this is not a research paper. Please write complete sentences, in order to be clear about the information in each section. The overall goal is to show you understand the content in each section. Write the information in paragraph form, not in bullet points. The suggested content/directions in each section should be deleted when no longer needed (including the directions in this paragraph). At submission, the only information needed in this report are the section headings and the client’s specific information.

Date of Report:

Client’s Full Name (Pseudonym):

Client’s Preferred Name:

Gender/Preferred Pronouns:

Date of Birth:

Demographics/Socioeconomic Status:

In paragraph form, give information about the client’s age, educational status (highest achieved, accomplishments, struggles, etc.), race, marital status, occupation, financial stressors, etc. Information included here helps to paint a picture of the client.

Presenting Problem

Describe information about the client’s current mental health and behavioral issues. What symptoms are creating problems with functioning in the areas of occupation, education, relationships, and general life issues?

Please keep the information in this section related to the symptoms being measured in the SCL-90-R.

Sources of Information

What assessment tool was administered? What date was it administered? Were there any issues with administration?

Background Information

Briefly summarize the highlights of what the client reported in the intake (biopsychosocial assessment). Are there notable events that occurred in the client’s lifetime? Keep the information limited to “big” events and/or information that is strictly related to the client’s mental health. This section will include several sentences that begin with statements like, “client reported.”

Keep this section concise but also allow the reader to have a better understanding of the client after reading.

Behavioral Observations

This section should include brief statements about anything significant you observed while administering the assessment tool or through clinical observation during the interview. This information should add to the overall picture of the client. Only add information that will help to better understand the client’s thoughts, feelings, and behavior; as well as gain information that will lead to the correct diagnosis or understanding of the client’s presenting problems.

Assessment Results

In a report where multiple assessment tools were administered, only the “significant” scores would be reported. However, since only one assessment tool was used for this assignment, please give a concise report of all the information obtained from the SCL-90-R. For example, what did the client score in each section? Was the score “significant?’

This section is only for objectively stating/reporting the results. In this section, do NOT try to explain why the results are the way they are. Do NOT try to find a deeper meaning for the client’s thoughts, feelings, and behavior. There is a different section for that.

Assessment Summary

Summarize all assessment information, especially as it relates to the presenting problem. For example, if the Beck Depression Inventory was being administered, there might be a statement in the summary section like this – “The client scored in the moderate range on the BDI, which is consistent with the client’s report of depressive symptoms.” Helpful tip: An “A” paper will go deeper than only making a similar statement as in the previous sentence. While it is important to not repeat information throughout the paper, this section might have some information that is repeated from a previous section, to be clear about how everything is connected.

In this section, look at all the information you have collected about the client (all assessments, observations, and background information) and make objective connections. In this case, objective means all personal biases are not considered when making the connections. It is important to remember that any thoughts about a client’s intentions, thoughts, and feelings are conjecture and not factual – no matter how right you think you are!

Diagnosis

Provide the DSM-5-TR diagnosis. (The diagnosis should be related to the symptoms measured by the SCL-90-R. No other diagnoses will be evaluated since this is not a diagnosis course. The purpose is to show understanding of connecting assessment to the diagnostic process.) Provide a rationale for the diagnosis. Explain why the diagnosis selected is the best/true diagnosis for the client. Do not only copy and paste the diagnostic criteria from the DSM-5-TR. The criteria can be included, but there must also be an explanation of how the client specifically has a symptom that matches each part of the criteria. Each symptom mentioned must be included somewhere in the report. No new symptoms should be introduced in this section.

Suicidality

All clinical reports (and session notes) should mention how suicidality was assessed/addressed at each encounter. In this section, combine any information about the client’s suicidal history, ideations, and/or attempts – or lack thereof. This information may have been addressed in the intake assessment/biopsychosocial or the assessment tool.

If any suicidal ideations or attempts were reported, provide information on the steps taken to address these concerns. Did you do any additional screening? Did you make any plans with the client? Did you refer anywhere? Did you contact any supervisors? You may use any resources provided in this course and can attach multiple documents to the submission of the assignment, if needed.

Recommendations

What happens next for this client? List at least two recommendations and a rationale for each based upon the results. Examples for recommendations could include suggestions of specific goals for a treatment plan; a recommended theoretical orientation to use to conceptualize the needs of the client and client’s treatment plan; or referrals to other providers for more information (such as a psychologist for additional testing or a psychiatrist for an evaluation for psychotropic medication).

If you refer your client to another professional for more information, add the contact information for a real provider in your area. If there is not a real provider in your area, then you will have to think of a different service to meet that need for your client. The instructions say to list at least two recommendations, but if your client has more than two needs, then you will need to include more than two recommendations. You need a recommendation for every need. This is the purpose of an evaluation like this – to identify the needs of the client.

(When finished, sign your name – similarly to how a letter would be signed. Consider this report as something that is being presented to a client or another provider. Remember that it is never appropriate to sign your name with credentials you have not yet earned. Sign your name here with your current credentials and then also indicate somehow that you are in training – which is what makes you qualified to complete this assessment.)

Respectfully,

__________________________

Your name with credentials

Job Title

Work Address

Work Phone

Delete this section before submitting your assignment – This assignment will be primarily graded on the accuracy of the scoring of the SCL-90-R, the accuracy of the reporting of the results in the “Assessment Results” section, how well the “Assessment Summary” section combines the assessment results and the client’s reported symptoms to summarize what is going on with the client, and how accurately the “Diagnosis” section reflects the client’s reported symptoms and assessment results.

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