1.) Write a comprehensive clinical report starting with a description of all 28 category headings from the Youth Comprehensive Assessment (see attached), based on the case of Amy (see attached). Rearrange the material presented in the case description for your report to fit the categories in the order in which they are listed on the assessment report.
2.) When you believe there is insufficient or missing information for any of the sections, list what information you would find necessary for the case of Amy and discuss its significance to the case. (Ie: how might this missing information influence your thinking of the case?) Back up your arguments with some evidence from your notes or researched evidence from readings. Place these comments in the sections that is missing, marking it as “missing information”. All sections from the assessment need to be addressed.
3.) Conclude your report with the following sections:
A.) Problems that Need to be Addressed: This is your conclusion of which symptoms and/or problem areas need to be addressed to help the child. Include a statement after it says “as evidence by” … “as evidence by” means give specific observable behaviors from the case that supports its specific problem (for ex.: Problem: Anxious – as evidence by: biting her nails every day)
B.)Next, write a clinical formulation. Make sure that you do not just describe Amy’s problems or background information but also speculate on how her problems developed and how they are maintained. Explain and interpret the reasons for Amy’s problems, tying together the various details of this case and backing it up with researched evidence.
C.) Diagnostic Section (using DSM-5 format, ie: specify disorder names and their codes). Give details of your thinking as to how you reached any complete diagnoses or reached any rule-out/tentative ones. Again, back up your ideas with researched evidence.
D.) Multi-method assessment: Based on your research of the literature and what we have learned in class, provide a list of formal assessment devices you would consider using in order to assess any aspect of this case. Place under the heading: Further Evaluations Needed. This section must include: 1) the name of the tests/procedures, 2) why you would use them, 3) what type of results you would expect, 4) and the significance of these results for the case of Amy.
E) List your treatment goals. The treatment goals must match your problems that you need to be addressed sections. one way to figure out a treatment goal is to ask yourself, “what will the client look like or be doing if not experiencing this problem?”, Therefore, do NOT write “Client will be less depressed”, but instead “Client will use positive statements” or “Client will engage in two pleasurable activities per day” – specific, observable and measurable goals)
Sections 2, B, and C require citations from as many sources as you would like to use. Must be empirical sources.
The more assessment you use the better! (The use of a clinical interview also counts as a form of assessment)
