The assessment will be broken down into seven INDIVIDUAL sections: I. Demographic Information II. Presenting Problem III. Relevant History IV. Symptoms V. Case Formulation VI. DSM-IV Multiaxial Assessment (OR DSM-5 Equivalent) Axis I: __________ Axis II: __________ Axis III: _________ Axis IV: _________ G.A.F.: _________ VII. Treatment Plan NOTE: The treatment plan addresses immediate actions that need to be taken, along with specific goals. Treatment goals reflect what we know about the disorder and the recommended therapy. These goals range form immediate to long-term. Treatment goals also reflect the particular needs and concerns of the individual (ex. safety/hospitalization). The following will ALWAYS need to be addressed in your treatment plan: 1) How will the symptoms be managed? 2) Problematic behavior, thinking, and emotions 3) The stabilization of a client through medication (if needed), 4) How alterations in personality and relationships will be addressed If ANY of these issues are not addressed in the treatment plan, it is INCOMPLETE. These issues (however you present them) MUST be included.
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