Case Presentation: Assessment & Diagnosis (CPAD) Assignment Instructions Overview This Case Presentation: Assessment & Diagnosis (CPAD) is the first part of three parts of your Benchmark Case Presentation Final (CPF) comprehensive case
Case Presentation: Assessment & Diagnosis (CPAD) Assignment Instructions
Overview
This Case Presentation: Assessment & Diagnosis (CPAD) is the first part of three parts of your Benchmark Case Presentation Final (CPF) comprehensive case presentation due in Module / Week 7 of this course. The CPAD is called a formative assignment in that you will get to “practice” the assessment and diagnosis process. This is an essential first step toward 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 potentially do harm.
For this CPAD Assignment, you will complete an assessment and diagnosis of your approved case study client from Module 1 created with AI Copliot, as illustrated in the Case Presentation: Assessment & Diagnosis Instructions and Case Presentation: Assessment & Diagnosis Template documents found in Canvas.
Requirements
-This assignment is to be 6 pages in length, not including the title page and reference page.
-Please utilize APA 7th edition formatting, including headings, subheadings, and intext citations.
-The assignment requires at least 2 citations, one of which should be the DSM-5-TR (APA, 2022). Do not use any other version of the DSM. Additional references are to be scholarly articles published within the last five years unless they are considered seminal works in the field of study.
Instructions
You will use the Copilot generated client (Sarah) approved in Module 1 as a foundation of your case. You should have the diagnosis and basic information provided. You will expand this case as if you are collecting additional assessment data which will justify your diagnosis and provide additional history providing enough information about your client to complete future assignments (Conceptualization and Treatment Plan). Do not use AI tools for further research or writing for this client – fill in the information based on what you are learning about the disorder/diagnosis in your research. The client you generated through Copilot and approved in Module 1 will be the client for your Benchmark Case Presentation Final (CPF). Your CPF will be comprised of three components: the Assessment and Diagnosis (CPAD) Case Conceptualization (CPCC), and the Treatment Plan (CPTP).
To complete this assignment:
1) Review the Case Presentation: Assessment and Diagnosis (CPAD) Instructions below.
2) Review the Case Presentation: Assessment & Diagnosis (CPAD) Grading Rubric.
3) Review the Case Presentation: Assessment and Diagnosis (CPAD) Template document. Follow the APA formatting as provided in the template. It is developed to help you stay aligned with assignment expectations based on the assignment instructions and grading rubric.
4) Write the Identifying Information and Reason for Referral/Presenting Problem.
5) After collecting all the clinical data, write up the Summary of Assessment. Do not leave any prompts blank or state client did not provide data. Be creative and include some information for each heading.
6) After writing the summary, present and justify your DSM-5 TR diagnosis. Most often in clinical work, this will include a primary diagnosis, comorbidity, and Z-codes. Please write the diagnosis in the format indicated in the DSM-5 TR and the example provided. Include clear criteria for the diagnosis and examples the client presents to justify each criterion.
7) As you begin to establish a diagnosis, consider the definition of Mental Disorder stated in the DSM-5 TR (p. 13-14) and consider the 4 Ds of diagnosing: deviance, distress, dysfunction, and danger. Consider onset of symptoms, duration of symptoms, frequency of symptoms, severity of symptoms (mild, moderate, severe), deviance from the norm, descriptive lineaments (good insight, poor insight, absent insight), and impairment in functioning. Consider differential diagnosis, course of the disorder (partial remission, full remission), and Risk: Suicide, Homicide, and other self-harming behaviors.
8) After you solidify your diagnosis, develop your diagnostic impression. The impression is an integration of DSM-5 TR criteria, specifiers, and severity with supporting evidence from the case study. Your diagnosis was provided when you generated the case however you need to clearly describe and justify your diagnostic impression.
Note: Your assignment will be checked for originality via the Turnitin plagiarism tool. Your Turnitin report should be less than 30%. AI report will also be verified and should be under 25%.
Please see the additional detailed explanations below for information that needs to be included in the CPAD.
Case Presentation: Assessment & Diagnosis Section Descriptions
Identifying Data
Date of Initial Assessment:
Client Name:
Age:
Gender:
Race:  Marital Status:
Sexual Orientation:  Employment Status:
Reason for Referral/Presenting Problem
Provide a brief reason the client has entered into counseling. This may be a triggering event such as a divorce, death, pandemic, loss of employment, bullying or client reported increase in signs, symptoms, impaired functioning, etc. Ideally, offering direct quotes on how the client describes the reason, presenting problem.
Confidentiality
This section should include a statement indicating that you reviewed confidentiality and the limitations therein.
Source of Information
Provide the source and the manner in which data was obtained in the preparation of this report. This includes both formal and informal or semi-structured assessments in the summary as well as throughout the case presentation as necessary to support your conclusions.
Assessment
Offer clinically relevant background information on the client. Write this out in paragraph format using complete sentences, no bullet points. Note: the case studies are limited and, if no data is present, note this under the heading below. The section should include the following in this order:
If no assessment data was available, then indicate how you would assess this client in real practice and the importance of assessing such an area.
Family and Home Background/Religious Background
Identifying information about parents and siblings (names, ages, occupations, etc.). Client’s perception of the home environment and relationships within the family. Critical family incidents may be included. Also note any events that triggered the client, family coming to counseling, e.g., precipitating events.
Educational History
Description of pertinent information in relation to educational background including academic achievement, school instances that were significant for understanding the individual and the client’s attitude toward education. Any assessment of information would be helpful.
Mental Health
Historical and as well as present signs, symptoms as well as mental health test results (formal and informal) such as DSM-5 cross-cutting symptom measures, Beck’s Depression Inventory, Beck’s Anxiety Depression Inventory, Patient Health Questionnaire, etc.
Mental Status Exam
When first meeting the client, what are your observations that would include speech; mood; affect; orientation to person, place, time; thought process; delusions; hallucinations; concentration, suicide ideation, etc. Also include any self-harm, e.g, cutting and/or harm to other.
Indicate onset of symptoms, duration of symptoms, frequency of symptoms, severity of symptoms (mild, moderate, severe), deviance from the norm, descriptive lineaments (good insight, poor insight, absent insight), and impairment in functioning.
Risk Assessment
A description of the assessment for Suicide, Homicide, and other self-harming behaviors. Indicate the level of risk assessed.
Client’s Physical/Medical Health
A statement of the client’s significant health history, current treatment, and medications.
Occupational History
A description of the client’s vocational history. Emphasis should be placed on current occupational functioning, history of work problems, and reason for change. Quality of work and satisfaction, and interests.
Sexual Adjustment
Current status, significant problems or disturbances in functioning, alternate lifestyles
Substance Use History
Description of client’s alcohol/drug use, patterns of use, and last use; as well as how often client uses and how much.
Spiritual Assessment
Does client believe in God? Attend church? What role does religious affiliation play in the client’s life? Are spiritual resources or issues important to clients? How does client describe God? What is the state of the client’s spiritual awareness? Additionally, an assessment of the religious background of the family is included.
Cultural Factors
Does the client have any factors such as acculturation, discrimination, etc. that impact the client and may be a source of signs, symptoms? How would the client explain the problem from their cultural lens?
Barriers to Treatment/Success
Are there personality factors, stages of change influences, or contextual factors that would influence the success of treatment?
Other Pertinent Data
Provide any other data points not captured from the sections above such as signs, symptoms, severity, onset, conditions, context that provide a clearer picture for the development and discernment of the diagnosis as well as client insight and motivation to treatment. As you begin to establish a diagnosis, consider the definition of Mental Disorder stated in the DSM-5 TR (p. 13-14) and consider the 4 Ds of diagnosing: deviance, distress, dysfunction, and danger. Consider onset of symptoms, duration of symptoms, frequency of symptoms, severity of symptoms (mild, moderate, severe), deviance from the norm, descriptive lineaments (good insight, poor insight, absent insight), and impairment in functioning. Consider differential diagnosis, course of the disorder (partial remission, full remission), and Risk: Suicide, Homicide, and other self-harming behaviors.
Diagnostic Impressions
DSM-5 Diagnosis
Primary – F 32.1 major depressive disorder, single episode, moderate (example)
Secondary – this may include another diagnosis such as GAD and also Z-codes.
Differential Diagnosis
Be sure to include diagnoses that you are still assessing for to rule them out (For example, you may be ruling out Generalized Anxiety Disorder, but the client has not yet had anxiety for 6 months or longer, so you’re keeping it as a provisional diagnosis). Make sure the rationale is directly connected to the DSM-5 TR.
Diagnosis Rationale
When writing up this section, make sure to offer each disorder criteria with case data to support the diagnosis. For each diagnosis, offer a separate paragraph in the diagnostic impression/rationale. Below are examples of incorrect and correct ways to write it up:
- Not correct– The client has a marked fear about one or more social situations. The individual feared that he will act in a way or show anxiety symptoms that will be negatively evaluated (offered DSM criteria only).
- Not correct – The client is depressed and noted sadness during the interview. The client isolated herself at home (problem, did not connect to DSM criteria).
- Correct – The client has marked fear in several social situations as evidenced by her fear when presenting in class, turning in a paper, and speaking with classmates (A1). She is fearful to speak up when feeling wronged by her supervisor, avoids chatting with co-workers, and isolates herself at home when asked to attend social events (A2). Her fears are founded on the belief that she will act in ways that will be perceived negatively by instructors, classmates, and coworkers (B3). Offer criteria and case study data to support it.
Make sure to use Z codes as needed that are found in the back of the DSM-5 TR. At times, if no disorder is appropriate, a z-code may be the principal diagnosis.
Make sure to offer a paragraph of z-codes in the diagnostic impression/rationale.
The first paragraph is only for the principal's diagnosis; the next paragraph is on the second disorder, and then additional paragraphs are for the other disorders. Each paragraph focuses on only one disorder. It is like building a court defense. If your records are subpoenaed or you transfer from a client to another counselor, they are not questioning your diagnosis as being incorrect, or inconclusive based on the diagnostic discussion. For the final paragraph, discuss your differential diagnosis.
This section should include a concise rationale for each diagnosis, differential diagnoses, and Z codes provided above.
References
At least offer the DSM-5 TR as a reference and one other scholarly reference minimum.