What are the key points of the Diagnostic assessment. How you might use them in a field placement? What are examples of how you would apply the material in the from the diagnostic in a field placement? Using the NASW's Code of Ethics, what are any key ethical principles that relate to the diagnostic and how does the content or how could it promote positive social change?

Diagnostic Assessment

Personal Information

Client Name: _________________________________________ Date: ___________

Address: ______________________________________________________________

Phone Number: ______________________ May we leave a message?YesNo

Email: ______________________________ May we leave a message?YesNo

Date of Birth: ______________ Age: ___________ Gender Identity: ___________

Marital Status: ______________________________

I.CULTURAL CONSIDERATIONS

It is imperative to learn about a client's cultural understanding of their situation. This information can be collected throughout the diagnostic interview where appropriate. Culture includes important elements that impact identity, such as race or ethnicity, sexual orientation, church affiliation, language, home of origin, educational experiences, military service, and so on. Approach this with curiosity and in a way that seeks to understand the client's context. Exploring cultural considerations is important to assist in assessing the presenting concern and will be key to devising plans to address it.

Example Questions: How important is your family in your life? What role do traditional healers play in your community? Tell me about your involvement with your church? How does your military experience impact your current situation?

II. REASON FOR ASSESSMENT (REFERRAL)

It is important to understand why the client has come to therapy. Was it mandated? Did someone else encourage them to? What are their presenting issues?

Example Questions: Can you tell me a little bit about what brought you in today?

Can you tell me about yourself and why you decided to seek therapy?

III. DESCRIPTION OF SYMPTOMS/PERCEPTION OF CONDITION

Example Questions: Can you tell me a bit more about what you've been experiencing? How have you been coping with this? How has this impacted your daily life?

IV. SYMPTOMS

In the following sections, you will be gathering information from the client about the reason for referral and what symptoms they are experiencing. When following up on symptoms, ask about the following: distress, severity, impact on daily functioning, and recent change in symptoms.

Example Questions: How long have you been feeling this way? On a scale of 0 to 10, 0 being no distress and 10 being the most distressed you've ever felt, how distressing are these symptoms you've been experiencing? Have any of your symptoms recently changed?

A. Depression Symptoms:

Example Questions: How has your mood been lately? How are you sleeping (ask about falling asleep, staying asleep, length of sleep, and quality of sleep)? How is your appetite? Have you had any thoughts of suicide? Have you engaged in any type of self-harm? Do you become easily annoyed or irritable?

Here are some potential areas to explore if they aren't brought up explicitly:

depressed mood most of the day fatigue/energy loss

diminished interest in activities difficulty concentrating

insomnia/hypersomnia difficulty making decisions

appetite changes significant weight loss/gain

feelings of worthlessness/hopelessness psychomotor agitation

feelings of guilt thoughts of suicide

history of self-harm/suicide attempt irritability

B. Anxiety Symptoms:

Example Questions: Do you find yourself feeling nervous, anxious or on edge? Do you think you worry about things that others don't worry about? Do you ever find it difficult to control the worry? Do you have trouble relaxing or feel like it's hard to sit still? Do you ever feel afraid, like something awful might happen?

Here are some potential areas to explore if they aren't brought up explicitly:

excessive worry/anxiety difficult to control worry

easily fatigued difficulty concentrating

irritability restlessness

muscle tension disturbed sleep

C. Adjustment Disorder Symptoms:

Example Questions: Have there been any situations in the past year that have been especially difficult, upsetting, or stressful?

Here are some potential areas to explore if they aren't brought up explicitly:

stressful situation marked distress

depressed/irritable mood sleep disturbances

poor performance in school difficulty concentration

worry sadness

with depressed mood with anxious mood

mixed anxiety and depressed mood

D. Current Psychiatric Medications:

Example Question: Can you tell me about any medications that have been prescribed to you, the dosage, and the reason for the medication?

V. MENTAL HEALTH HISTORY

Ask the client about prior mental health challenges.

Example Questions: Has any medical or mental health provider given you a diagnosis? Are there other times in your life that you've struggled with XXX? Are there other things you've struggled with in the past?

VI. PSYCHIATRIC TREATMENT HISTORY

Ask about prior treatment and hospitalization.

Example Questions: Have you received any mental health treatment in the past? Have you ever reached out to a mental health provider? Have you ever been hospitalized related to your mental health? Have you ever gone to a residential treatment facility or participated in a partial hospitalization program (PHP) or another intensive form of treatment?

VII. DEVELOPMENTALINCIDENTS

It's important to note any problems during their mother's pregnancy.

Example Questions: Were there any problems during your mother's pregnancy with you? Were there any problems during your birth? Did you hit milestones within an appropriate timeframe as a small child (crawling, walking, talking)?

VIII. HISTORY OF ABUSE, TRAUMA, AND/OR MALTREATMENT

It's helpful to inform clients that you'll be talking about trauma. You might say something like, "Now I'm going to ask you some questions about difficult things you may have experienced in your life."

Example Questions: Were you ever hurt by someone taking care of you? Sometimes people have experienced traumatic events in their life. Has this ever happened to you? This could include your own experiences of physical, sexual, or psychological abuse or the abuse of someone close to you. Have you experienced, witnessed, or been confronted with a traumatic event?

IX. HISTORYOF ALCOHOL AND/OR DRUG USE AND TREATMENT

A.Current Use:

Example Questions: In the past month, how many alcoholic drinks have you had? In the past month, what type of drugs have you used? How much? Has anyone ever told you that you should cut down on how much you're using?

B. Treatment History:

Example Questions: Have you ever received treatment related to your substance use? What was helpful about this treatment?

C.History of Use:

Example Questions: When was the first time you used drugs or alcohol?

X. PHYSICAL HEALTH

A.Current Medical Conditions:

Example Questions: What medical conditions do you have?

B. Current Medications:

Example Questions: What medications are you taking for medical illnesses?

C. HealthHistory:

Example Questions: What type of medical problems or challenges have you experienced in your life?

XI. FAMILY HEALTH HISTORY

A.Mental Health:

Example Questions: What mental health challenges have your family members experienced? Have any of your family members been diagnosed with a mental health disorder?

B.Physical Health:

Example Questions: What type of medical conditions do your family members have?

C.Substance Use:

Example Questions: Do any of your family members struggle with alcohol or drug use?

XII.FUNCTIONING/IMPAIRMENTS

A. Basic/Economic Needs:

Example Questions: How are the challenges you've discussed today impacting your ability to meet your basic needs?

B.Education and Employment:

Example Questions: How are the challenges you've discussed today impacting you at work (or school)?

C.Relationships:

Example Questions: How are the challenges you've discussed today impacting your relationships?

XIII.STRENGTHS

Example Questions: Tell me about your skills and strengths. Who is your biggest cheerleader? What would they say your three greatest strengths are? What skills have you used to cope up to this point?