What assessment tools would you want to administer if any?
What are the principal symptoms contributing to the diagnosis proposed? Clearly explain, providing details. What does the criteria in the DSM states and how does this compare to his symptoms? Does this disorder overlap with another or can you rule out other disorders?
Discuss Bob's strengths. These will facilitate constructive work with him.
Delineate Bobs opportunities for growth and/or improvement.
Looking to the next visit and beyond, what is your preliminary sketch of the treatment goals you have for Bob? Why do you identify these goals as appropriate for Bob?
What will you explore with Bob in future visits (e.g., interpersonal, aspirations)? Present rational. Why do you want to this information? (
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