Description I. Introduction A. Summarize the client. What is the rationale for seeking counseling?
II. Biopsychosocial Summary
A. Describe the problem that brought the client to treatment. i. Make sure to address any problems, issues, or challenges the client may be facing.
B. Explain the symptoms affecting the client. i. What are the behavioral symptoms? ii. What are the cognitive symptoms? iii. What are the emotional symptoms? iv. What are the physiological symptoms?
C. Identify any environmental factors that may be contributing to the client’s problem.
D. Identify any potential harmful behavior: i. Aggression ii. Harm to others iii. Harm to self iv. Criminal activity v. Impulsive behaviors vi. High-risk activity
E. Determine if the client has a family history of the diagnosis. Consider how this may affect the client. F. Use evidence-based research to support the biological factors presented in the case.
G. Outline how the client identifies him- or herself in regard to cultural characteristics. Make sure to add rationale for any answers that are not straightforward. i. What are the addressing factors?
a. Age and generational influences
b. Developmental disabilities (acquired at birth or during childhood)
c. Disabilities acquired later in life (e.g., traumatic brain injury, multiple sclerosis, stroke)
d. Religion and spirituality
e. Ethnic and racial identity
f. Socioeconomic status
g. Sexual orientation
h. Indigenous heritage
i. National origin j. Gender
H. Summarize how the client culturally identifies him- or herself.
i. With the identifiers above, how does the client culturally identify him- or herself? ii. What is the order of importance for the client? Assessment III. Co-occurring Disorders
A. Identify any co-occurring disorders. B. Describe the initial DSM diagnosis. i. What is the overall descriptor of the diagnosis? ii. What criteria must be met to meet the diagnosis? iii. Describe which client behaviors are being used to meet the diagnostic criteria.
C. Discuss the rationale behind the diagnosis. i. Identify what other diagnoses should be ruled out. Make sure to provide rationale. ii. Identify limitations with this diagnosis. Make sure to provide rationale.
D. Use evidence-based research to support your justification. IV. Addiction Assessments
A. Describe how the assessment was administered.
B. Describe the assessment scoring.
C. Summarize the assessment results.
i. How do you interpret the results? Plan V. Recommendations
A. Summarize what you recommend for this client based on the information collected.
i. Describe what you recommend for recovery.
ii. Describe what you recommend for relapse prevention.
resources you would provide to the client. Rubric Guidelines for Submission: Consider using the headings from the critical elements outlined above when drafting your DAP note, as you will do this when you submit for your final project. You may also consider using double spacing, 12-point Times New Roman font, and one-inch margins, although none of these specifications are required for the draft version. Critical Elements Pro
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