Case Presentation Assessment & Diagnosis (C-PAD) Instructions

This is the first part of your Case Presentation assignment that will be due formally in Module 7: Week 7 of the course. This is a formative assignment (draft) in that you will get to “practice” the process of assessment and diagnosis. This is an essential first step towards the development of a sound case conceptualization and treatment plan. It is the foundation of the “golden thread” when working with a client. If you miss the mark here, it can lead your treatment plan astray and potential harm.
For this assignment, you will complete the Assessment and Diagnosis portion of the case presentation as illustrated in the Case Presentation of Penny CPAD example.
This assignment is 4 to 7 pages in length in APA format, which includes a cover page, headings, subheadings, intext citations, and a reference section. The assignment requires at least one citation, e.g., DSM-5 (see p. 324 of APA Publication Manual 7th edition on how to cite correctly). Note if other sources are used they are to be scholarly articles published within the last five years unless there are considered seminal works in the field of study.
To complete this assignment, do the following:

1) Review the Case Presentation of Penny CPAD example and Case Presentation: Assessment & Diagnosis (C-PAD) Template.
2) Follow the APA formatting exactly as provided in the template (i.e., cover page, headings, subheadings, references). It is developed to help you stay aligned with assignment expectations based on the assignment instructions and grading rubric.
3) Review all data you have on your client.
4) Offer the “identifying information.” Note the date of the initial assessment is the date of the initial interview of your classmate, the CIR video. Use the clients’ “real” name (e.g., Clare, George) since it is a case study. If it was a real client you would use a pseudo name.
5) Write up the “Presenting Concern.” This is the reason for referral and the presenting concern – why the client initially sought treatment.
6) After collecting all the clinical data, write up the “Background, Family Information, and Relevant History.” This is the clinically relevant historical information on the client.
7) Then write up the “Problem and Counseling History.” This section offers all the signs, symptoms, onset, duration, frequency, areas of dysfunction, etc. If assessment information is provided in the case study (e.g.,. MSE), use this assessment data here as well.
8) Then develop your DSM-5 diagnostic impressions (diagnosis). Most often in clinical work, this will include a principal diagnosis, comorbidities, and z-codes. You can also offer “provisional” if not all of the criteria are met for the disorder. You can “consult” with your clinical team and other classmates as needed in the development of the diagnosis.
9) After you solidified your diagnostic impression then develop your “Discussion of Diagnostic Impression.” The diagnostic impression write-up is an integration of DSM-5 criteria, specifiers, and the severity with supporting evidence from the case study.

Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.