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.