Thoroughness–the written report

3-5 typewritten pages in APA.

Thoroughness–the written report reflects information gathered from all of the following

areas:

Introduction

 (client’s first name in quotes, age, race, disability status, gender, marital status, number of children, and

any abnormal appearance), Presenting problem

(what precisely brought the client into treatment? defined in behavioral terms with information as

to the where, when, what, and how of the problem, significant people involved and a brief history of the problem),

Family and social background

(describe the family’s relevant medical/psychological problems, education/career

achievements, quality of their relationships with each other and with the client, and describe the type of friendships the

the client has had in the past and has currently),

Educational information and career information

(highest grade or degree achieved, past and current occupations,

grades in school, any special learning difficulties, reasons for transitions from occupation to occupation, quality of work

relationships– especially with authority figures),

Medical/psychological history

(list drugs currently prescribed, any health problems present and past, history of

psychological treatment and client’s attitudes toward treatment), worth 10 pts

Drug/alcohol history

(list drugs used and the who, what, where, when of drug use past and present, has client

experienced: blackouts? memory lapses? early morning drug use? using the drug in increasing amounts? withdrawal

symptoms?), legal history a

Summary and conclusions

–include mention of your impressions and what you ruled out when making your

diagnosis

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